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The 

Medical and Surgical 
Reporter 



EDITED BY 

Harold H. Kynett, A. M., M. D. 



JANUARY TO JULY, 1893. 



VOL. LXVI1I. 




Philadelphia : 
R. C. PENFIELD, PUBLISHER, 

P. 0. Box 843. 
1893. 



1X 

CONTRIBUTORS. 



ALBU, Dr., Berlin. 

.0 " '\ y !' 

BALDY, J. M., M. D. 
BARKER, T. RIDGWAY, M. D. 
BARNES, I. C, M. D., Topeka, Kan. 

' BERGrEY, M. D., North Wales, Pa. 

BRASINS, W. L., M.D., Gallatin, Mo 
BULETTE, LORENZO D., of the Philadelphia Bar. 
BURR, WM. H., M.D., Wilmington, Del 
BUTLER, FRANK P., M.D., Marshaltown, la. 

CADY, N. W., M.D., Logansport, Ind. 
CARPENTER, J. G.. M.D., Stanford, Ky 
CARRELL, J. B., M.D., Hatboro, Pa. 
CARTLEDGE, A. M., M.D. Louisville, Ky 
CATTELL, HENRY W., A.M., M.D 
CECIL, JNO. G., M.D., Louisville, Ky. 
CHEATHAM, WM., M.D.,Louisville, Ky. 
CHENOWETH, JAS. S., M.D., Louisville, Ky. 
CORDIER, A. H., M.D., Kansas City, Mo. 
CURRIER, ANDREW F., M.D., New York City 
CURRIER, JOHN M., M.D., Newport, Vermont.' 

DALLAS, ALEX., M.D., New York 

WILLIAM A.M., M.D., Salina, Kansas. 
DIXON, SAMUEL G., M. D. 
DUGAN, W. C, M.D., Louisville, Ky. 

EDMONSON, M. M., M.D., Dallas, Texas. 
EVANS, T. C, M. D., Louisville, Ky. 

GEYER, H. REASONER, M. D., Norwich 
GIBNEY, V. P., M. D. 
GODDELL, WILLIAM, M. D. 
GUNTERMAN, P., M. D. 

HALL, G. V., M. D., LL. B, Wheaton, Texas. 
HAMILTON, JOHN B., M. D., LL. D., Chicago 
HAMMOND, WILLIAM A., M. D. g 
HAYS, J. E., Dr. 
HERBST, A., Dr. 

HOFFMAN, JOSEPH, M. D., Philadelphia. 
H0G ^N, SAMUEL MARDIS, M. D., Union Springs, 

HOLMES, JOHN C, M. D., Cranbury, N. J. 

INGALS, E. FLETCHER, M. D., A. M., Chicago. 

JACKSON, EDWARD, A.M., M.D 

JONES, MAY A. DIXON, M.D., Brooklyn, N Y 

JUSTICE, J. D s , M.D., Belleplaine, Kan. " ' 

KEMPF, E. J., M. D., Jasper, Md. 
KRAUSE, WILLIAM C, M.D., Buffalo, N. Y. 

LADD, G. D., M.D., Milwaukee, Wis. 
LAMBERT, J. R., M.D., Quincy, 111. 
LARRABEE, JOHN A., M.D., Louisville, Ky. 
LINK, W. H., M.D., Petersburgh, Ind. 
LYDSTON, G. FRANK, M.D. 
LYMAN, HENRY M., A.M., M.D., Chicago, 111. 



MANLEY, THOMAS H., M.D., New York. 
MANN, M. A., M.D. 
MANN, MATHEW D., A.M., M D 
MANSFIELD. ARTHUR D., M.D., Baltimore, Md 
MATHEWS, J. M., M.D. 
McMURTRY, L. S., M.D., Louisville, Ky. 
McNUTT, W. p., M.D., M.R.C.S., Ed., etc., San 
Francisco. 

MALLOY, RUSHTON, M.D., Caledonia, Miss. 
MARECHAL, EDWIN L., M.D., Mobile, Ala. 
MITCHELL, M. R., M.D., Topeka, Kas. 
MONTGOMERY, E. E., M.D., Philadelphia. 
MOON, ROBERT C, M.D., Philadelphia, Pa. 
MORRIS, ELLISTON J, A.M., M.D., Philadelphia. 
MORTON, THOMAS, S. K., M.D P 
MOYER, HAROLD, N., M.D., ] „. . 
LYMAN, HENRY, M., A.M., M.D., J Chlca g°> HI- 

NORBURY, FRANK P., M.D., Jacksonville, 111 
NORTON, H. G., M.D., Trenton, N. J. 

PALMER, E. R., M.D., Louisville, Ky. 
PARISH, WM. H., M.D. 
PARK, ROSWELL, Prof. 

PARK, ROSWELL, A.M., M.D., Buffalo, N. Y. 
PORTER, WILLIAM W., Esq. 
PRICE, JOSEPH, A.M., M.D., Philadelphia. 
PRICE, MORDICAI, M.D., Philadelphia 
PRYOR, JAS. E„ M.D., Logansport, Ind. 
PURDON, JOHN EDWARD, A.B., M.D., Tampa, 
Florida. r 

ROBERTS, JOHN B., A.M., M.D. 
ROBISON, JOHN A., A.M., M.D., Chicago. 
RUSSELL, F. H., M.D., Bluffdale, 111. 

SCHOOLER, LEWIS, Des Moines, Iowa. 
SHOEMAKER, JOHN V., A.M., M.D. 
SMITH, A. LAPTHORN, B. A., M.D., M. R. C. S , 
England. 

STIMPSON, A. 0., M.D., CM., Thompson, Pa. 

STOCKTON, CHAS. G., M.D. 

SUTHERLAND, H. H., M. D., Harrington, Kan. 

TALLEY, R. P., M.D., Temple, Texas. 
TAYLOR, J. MADISON, M.D. 
TERRY, HERBERT, M.D. , Providence, R. I. 
THOMAS, JNO. J., M.D., Youngstown, 0. 
TOWNSEND, E. H., M.D., New Lisbon, Wis. 
TULL, M. GRAHAM., A.M., M.D., Philadelphia^ 

VANCE, AP. MORGAN, M.D., Louisville, Ky. 
VAN EMAN, J. H., M.D. 

WILLARD, DeFORREST, M. D. 
WILMARTH, A. W., M.D. 
WALL, G. A., M.D., Topeka, Knn. 
WRIGHT, J. S., M.D., Brooklyn, N. Y. 
WOLFF, L., M. D., Philadelphia. 



INDEX. 



Abortion — Treatment of, 423. 
A Case of Living Xiphopagus, 28. 
A Case of Pneumonia with. Remarks, Kempf, E. J., 
894. 

A case of Diphthretic Croup in which a Tracheotomy 
Tube was worn for sixty days, Wharton, H. R., 
923. 

Abscess of Frontal Sinus, Wall, G. A., 166. 
Abuse of Milk in Albuminurias, 345. 
Acne, 301. 

Actinomycosis Hominis, 158. 

Action of Chloroform upon the Human Being, 308. 

Acute Forms of Gastric Hyperasthemia, 746. 

Intestinal Obstruction — Treatment of, 545. 

A Discussion of the Legal Aspect of Criminal Abor- 
tion, Porter, William W., 655. 

Administration of Chloroform and Its Dangers, 
103-624. 

Of Ether for Surgical Operations, Morris, Ellis- 
ton J., 569. 

Advantages of Antiseptic Irrigation of Parturient 
Canal Before and After Labor, Barker, T. Ridgway 
845. 

Address on Hygiene, Dixon, Samuel G., 876. 

After-effects of Chloroform, 913. 

After Effects of Chloroform, 273-420. 

Albuminuria During Pregnancy, 108. 

All That is Necessary, 211. 

American Medical Association, 930-962. 

Amputation at the Hip ; Re-section of the Rib, 171. 

At Hip Joint: Encysted Cartilaginous Tumor 

near Subclavian Vessels; Operation on the 

Fifth Nerve, 691. 
Anaesthetics — New Local, 516. 
Aneurism of Cheek, 540. 

Animal Extracts: Mode of Preparation and Physio- 
logical and Therapeutical Effects, Hammond, Wil- 
liam A., 243. 
Anti-Cholera Vaccination, 703. 
Anti-Syphilitic Treatment — Proper Duration, 273. 
Aortic Aneurism by Electrolysis Through Introduced 

Wire— Tieatment of, 155. 
Appendicitis, 77-116-292-697-824. 

Medical and Surgical Management, 107. 
Plea for Early Surgical Treatment, Cordier, 
A. H., 1. 

Apotheosis of Dirt, Link, Wm. H., M. D., Petersburg, 

Ind., 319. 
Apyretic Scarlatina, 861. 
Aristol, 39. 

Armour Institute, 359. 

Arsenical Treatment of Multiple Sarcomatosis of the 
Tegumentary and Mucous Surfaces, 754. 

Artificial Induction of Labor, 698. 

A Short Umbilical Cord, Carroll, J. B., 132. 

Aseptic and Antiseptic Care of Lying-in Woman and 
New-Born Child, Norton, H. G., 16. 

Asepsis and Antisepsis in the Lying-in Chamber, 155 
In Obstetrics, Mitchell, 366. 

Attempt to Make a Radical Cure in Three Cases of 
Hernia, Wright, J. S., 168. 

Aural Symptoms of Neurasthenia, 153. 

Auto-Suggestion — The Kitsune-tsuki, 185. 

Bacteriological Notes, 945. 
Bacteria of the Stomach, 590. 

Bi-Lateral Oophorectomy for Cure of Osteomatacia,466. 
Bacillus Coli Communis in Inflammatory Affections of 
Anus, 705. 

Of Eclampsia, 516, 



Birth in the Coffin After Maternal Death, 621. 
Biology of Cholera Bacilli, 908. 
Bow-legs, 595. 
Black Eye, 87-545. 

Bleeding Fibroids and Endometritis, 435. 
Brain Syphilis, 495. 
Brittle Bones, 589. 
Bubo, 332. 

Bugs and Bug Poisons, 291. 

Burns of Conjunctiva by Instillation of Calomel, while 
giving Potassium Iodide Internally, 194. 

Can a Septic Bullet Infect a Gunshot Wound? 78. 
Cancer of Oesophagus — Rupture into Thoracic Cavity, 
541. 

Carbolic Acid in Surgery, 515. 
Carcinoma — Mammas, 492. 

Thyroid Gland, 507. 

Uteri, Montgomery, E. E., 10. 
Cardiac Stimulation in Pneumonia, 370. 

Stimulation in Pneumonia, Larrabee, John A., 
364. 

Caries of the Coccyx, 154. 

Caesarean Section for Eclampsia, 347. 

Case of Cerebral Surgery, Dugan, W. C, 130. 

Poisoning of Methyl Blue, 66. 
Catarrhal Nephritis in Syphilis, Tuberculosis and 
Leprosy (Lepra), 181. 

Sore Throat — Treatment of, 40. 
Cautionary Facts, 754. 
Cerebral Concussion, 177. 

Syphilis, Hays, J. E., 86. 
Spastic Paralysis, Willard, DeForrest, 762. 
Certain Forms of Septicemia Resulting from Abortion, 

Currier, Andrew F., 214. 
Cervical Stenosis, by Bi-lateral Discission — Treatment 
of, 744. 

Chloroform as a Haemostatic, 914. 
Chloroform Anaesthesia and Its Administration, Gun- 
terman, P., 806. 

Anaesthesia and Its Administration, 851. 

How to Administer Properly, 515. 

Internal Uses of, 39. 
Cholera, Epidemic of 1892, 29. 
Choleeystotomy, 889. 
Chronic Articular Rheumatism, 821. 

Inversion of Uterus, Brasius, W. L., 446. 
' Pulmonary Phthisis in Later Adult Life, 433. 
Clean Cistern Water, to, 112. 

Clinical Observations in New York, Link, W. H., 

Petersburg, Ind., 927. 
Clinical Classification of Hip Disease, 116. 

Contributions on Intestinal Ocelusion, 784. 
And Experimental Contribution to Treatment 
with Creasote of Pulmonary Tuberculosis, 
Albu, 89. 

Investigations Regarding Enlarged Thyroid and 

Operations for Relief, 702. 
Observations in New York, Link, W. H., 681. 
Club Foot, 68. 

Coagulability of Blood in Parturition a Factor in 

Occurrence of Postpartum Hemorrhage, 670. 
Cocaine Antidotes, 76. 
Cocaine Antidotes, 913. 
Cocillana, 316. 

Cod Liver Oil in Rheumatics — Use of, 76. 
Coffee as a Cause of Itching, 404. 
Cold Bed, The, 223. 
Congenital Club-foot, 821. 
Syphilis, 114. 



Index. 



iii 



Consumption Caused by Cows, 671. 
Continued Administration of Digitalis, 667, 
Contributions to Pathology of Psoriasis, 829. 
Correct Gymnastic Positions, 67. 
Country Physician, The, Holmes, John C, 336. 
Criminal AbortioD, Parish, Wm, H., Jr., 644. 

Responsibility in Early Stages of General Par- 
alysis, Norbury, Frank P., 44. 
Cry of Children, the, 913. 
Croup Treatment, 433. 

Cuneihysterectomie — New Operation for Flexion of 
Uterus, 385. 

Curette in Obstretric and Gynecological Practice, Cecil, 

Jno. G., 50. 
Cutaneous Cicatrices of Syphilis, 627. 
Cystic Goitre with Cases in Practice, 953. 

Dandruff Cures, 404. 

Death in Infants from Hypertrophy of the Thymus, 
464. 

Deaths Under Chloroform, 196. 

Decidua in the Diagnosis of Extra Uterine Pregnancy, 
755. 

Delirium Tremens, Treatment of, Without Choloral 

Bromide of Potassium or Opiates, 159. 
Dermoids, Price, Joseph, 561. 

Destiny of a Ligature used in Ovariotomy After Five- 
and-a-half Years, 466. 
Diabetes Following Extirpation of the Pancreas, 754. 
Mellitus, by Means of Pancreatic Juice — Treat- 
ment of, 190. 
Diagnosis of Cancer of the Pancreas, 228. 
Did not Know it was Loaded, 471. 
Diet in Obesity, 433. 

Different forms of Iritis and their Treatment, Mansfield, 

Arthur D., 401. 
Differentiation of the Typhoid and the Coli Communis 

Bacilli, 269. 

Of Bacillus Coli Communis and Bacillus Typho 
Abdominalis, 468. 
Dilute Nitrohydrochloric Acid, 635. 
Diphtheria Treated by Tartaric Acid and Corrosive 
Sublimate of Mercury Method, Tull, M. Graham, 809. 
Diphtheritic Angina, by Chromic Acid — Treatment of, 
388. 

Dirty Midwifery, 382. 

Discriminating Diagnosis Between Cerebral Hemorrh- 
age and Acute Softening, 154. 
Dislocations, 363. 

Distribution of Bacilli of Diphtheria in the Human 

Body, 467. 
Double Excision of the Knee, 59-221. 
Do the Sick ever Sneeze, 948. 

Drunkenness with Strychnia — Treatment of, 784. 
Drunk or Dying, 524. 

Duboisine in Treatment of Hystero-Epileptic Convul- 
sions, 316. 

Early Extirpation of Tumors, 154. 

Treatment of Congenital Club-foot, Hogan, 
Samuel Mardis, M. D., 197. 
Echinococcus in the Throat, 228. 
Eclampsia of Pregnancy, Barnes, I. C, 517. 

Treatment of, 435. 
Ectopic Gestation, 596. 

Enlargement of Cervix during Pregnancy, 898. 
Enuresis Diurna, 901. 
Epilepsy, 956. \ 

EDITORIAL— 

Drainage needed, 971. 

Extra Uterine Pregnancy, 666. 

Gynecology Among the Insane from Another 

Point of View, 341. 
Home Quarantine, 141. 
Innocents Abroad, 263. 

Medical Examiner's Bill for Pennsylvania, 548. 
Legislation in Georgia, 781. 
Schools — Their Management. 



" Much Ado About Nothing," 616. 

National Quarantine, 100. 

New Medical Law in Pennsylvania, 856. 

Penetrating Gunshot Wounds of the Abdomen, 743. 

Practical Cleanliness, 436. 

Professional Courtesy, 546. 

Quarantine Problem, 97. 

Support the Medical and Examiners' Bill, 488. 

The ReductioAd Absurdum, 386. 

The New Quarantine Law in Pennsylvania, 907. 

The Significance of the Black-Bail, 905. 

The Itching Palm, 942. 

A Modern Don Quixote Charging a Wind-mill, 
302. 

An Agnew Memorial, 179. 

Abdominal Surgery — Its Revolution, 140. 

Anaesthesia, 500. 

A Gratuitous Insult, 827. 

Board of Health, Editor Public Ledger, 63. 

Cholera This Season, 421. 

Cleared Up, 589. 

Department of Public Health, A, 61. 
Editorial, 25. 

Examination of Sputum for Tubercle Bacilli, 224. 

Extra Uterine Pregnancy, 666. 

Fortified Against Microbes, 783. 

Furor — Operandi and Modern Listerianism, 855. 

Gynecology Among the Insane, 62. 
Effects of Acids on Functions of the Stomach, 273. 
Effect of Intra-Nasal Obstructions on the Singing 
Voice, 64. 

Electricity in Gynecology, Successes and Failures with 

Smith, A. Lapthorn, 6. 
Emergencies, 109. 

Epicystotomy for Removal of Catheter from the Blad- 
der, 850. 

Epileptic Seizures During Tonsillotomy, 584. 
Epithelioma : Traumatic Epilepsy, 254. 
Epistaxis, 709. 

Etiology of Acute Bright's Disease, 77. 

Of Emphysematous Cellulitis, 705. 

Of Prostatic Hypertrophy, Lydston, G. Frank, 
(Monograph No. 2), 1. 
Exanthemata During Puerperium, 830. 
Exophthalmic Goitre, 351. 
Expectant Treatment in Typhoid Fever, 115. 
Experimental Typhoid Fever, 304. 
Extra Uterine Pregnancy, 69-368. 

Pregnancy, Price, Mordecai, 764. 
Equitable Responsibility of Inebrity, 33. 

Facts to be Considered by Obstetricians, 820. 

False Neurasthenia, 96. 

Fatal Rupture of Pyosalpinx, 156. 

Suppuration Beneath the Shoulder Blade, 144. 
Faults in Voice Production which Lead to Voice Dis- 
ease, 795. 

Femoral Aneurism—Treatment by Compression, Mol- 
Filoy, Rushton, 597. 

stula in Ano, Operation, 900. 
Five Cases of Vaginal Hysterectomy for Malignant 

Disease of the Uterus— all recovered, McNutt, W. F. 

79. 

FORMULAE— 

Abdominal Operation Wounds, Dressing for 869. 
Abscesses, 868. 

Alcoholism (Chronic), 826-868. 

Acute Laryngitis in Children, 855. 

Agreeable Salicylic Mixtures, 753. 

Allingman's Ointment for Hemorrhoids, 310. 

Anal Fissure, 428 

Anaemia and Chlorosis, 714. 

Antiseptic Dental Cream, 514. 

Asthma, 113-714. 

Barbers' Itch, 514. 

Battery fluid, 869. 

Bright's Disease, 869. 

Bronchial Asthma, 638. 



Index. 



Burns, Application for 428, 

Burns in Children, 311. . 

Burns of the Eye, 310. 

Carbuncle, 753. 

Catarrh, Acute Nasal, 113. 

Cement for Glass to Glass, 311. 

Cementing Iron, 416. 

Chancroids, 714. 

Chillblains, 753. 

Chloral in boils, 753. 

C. Chlorodyne, 548. 

Cholera Cure, 310. 

Cholera Infantum, 753. 

Chronic Bronchitis and Emphysema, 795. 

Chronic Eczema., 753. 

Chronic Rheumatism, 310. 

Cleaning Wall Paper, 311. 

Coccydnia, 112. 

Collodion for Gouty Joints, 714. 
Corneide — English Corn Cure, 310. 
Constitutional Syphilis, 713. 
Counter-irritant in Diseases of the Chest, 714. 
Creasote Treatment of Tuberculosis, 113. 
Croup, 635. 

Cutaneous Diseases, 753. 

Cystitis, 635. 

Cystitis in Women, 310. 

Dentifrices for Mercurial Stomatitis, 635. 

Detection of Pus in Urine, 112. 

Diabetes, 869. 

Diphtheria, 310-427. 

Disguising the Taste of Cod-Liver Oil, 714. 

Disguise Turpentine, 713. 

Dressing for Cuts, Sores, Scalds, etc., 533. 

Dry Pleurisy, 752. 

Dusting Powder for Children, 428. 

Dysentery, Chronic, 869. 

Dysentery, Acute, 869. 

Dysmenorrhoea, 868. 

Earache, 753. 

Eczema, (Chronic) 868. 

Emulsion, Castor Oil 112. 

Enteritis, 869. 

Epilepsy, (to Prevent Nocturnal Fits) 868. 
Epistaxis, (in AnEemic Cases) 868. 
Erysipelas, 634. 

Excessive Thirst in Diabetes, 753. 
Exophthalmic Goitre, 868. 
Expectorant, 428. 
Fissures of the Breast, 868. 
Fissures of the Nipples, 427. 
Fissures of the Tongue, 868. 

Frost Bite, 112. . . 

Frosted Feet, 634. 
Gastralgia, 541. 

General Nervousness and Depression of Spirits, 714 

Gonorrhoea, 112-514. 

Gonorrhoea in Females, 513. 

Habitual Abortion, 714. 

Habitual Constipation, 112. 

Hard Tooth Soap, 310. 

Hiccough, 714-868. 

Hooping Cough, 714. 

Impetigo Contagiosa, 514, 

Inhalation for Whooping Cough, 665. 

Ingrowing Toe-nail, 869. 

Intestinal Fluxes, 635. 

Iodated Water in La Grippe, 428. 

Irritable Bladder with Acid Urine, 550. 

Irritable Cough, 635. 

Laundry Starch Polish, 513. 

Leather Bronze, 311. 

Liniment for Neuralgia, 112. 

Liniment of Subacetate of Lead, 428. 

Local AnEesthesia, 635. 

Local Psoriasis, 514. 

Lumbago, 752. 

Mercurial Stomatitis, 869. 

Metal to Glass, Cement, 311. 



Mucous Patches in the Mouth, 634. 
Nervous Cough, 112. 
Nervous Debility, 428. 
Neuralgia, 753. 

Neuralgia in Dysmenorrhea, 310. 
Ointment for Chronic Gonorrhoea, 310. 
Ointment for Eczema, 310. 
Ointment for Hemorrhoids, 112. 
Otorrhoea, 753. 
Pain in the Eye, Disease. 
Painful Hemorrhoids, 428. 
Painless Dilatation of Cervix Uteri, 112. 
Paralysis, 752. 

Patches on Skin and Mucous Membranes, 752. 
Patent Leather Varnish; 311. 
Pills of Iodide of Potassium, 948. 
Pleurisy, 752. 

Pomade for Psoriasis of Scalp, 514-635. 
Post-partum Uterine Pains, 539. 
Prophylactic for Tonsillitis, 427. 
Protracted Croup, 713. 
Pruritus Ami, 311. 
Pruritus of the Vulva, 868. 
Removal of Mother's Marks, 311. 
Removing Warts, 112. 
Rheumatism, Chronic, 753. 
Ringworm, 427. 
Round Worms, 515. 
Santonin for Children, 311. 
Santonin Lozenges, 427. 
Scabies and Head Lice, 714. 
Scrotal Eczema, 428. 
Seborrhea of Scalp, 635. 
Secondary Syphilis, 714. 
Serous Diarrhoea, 112. 
Significance of Subjective Cerebral Symptoms in 

Middle Ear Inflammation, 116. 
Small Hemorrhoids and Pruritus Ani, 112. 
Solution for treatment of Chancre, 113. 
Soothing Syrup without Opium, 514-868. 
Sore Throat, 514. 
Substitute for Mothers' Milk, 428. 
Sulphur Iodide in Acne, 634. 
Swollen Eyes, 753. 
Syphilis, 753. 

Syphilitic, Oral, Lingual and Pharyngeal Lesions, 
427. 

Syphilitic Ulcers, 428, 665. 
Tape worm, 112. 
Tsenifuge for Children, 514. 
Tertiary Syphilis, 713. 
Threatened Abortion, 310. 

Thymol and Salicylic ^cid against Foetid Breath, 
427. 

Tonic Laxative, 635. 

Tonsillitis, 310. 

Tooth ache, 497. 

Transfusion Fluids, 113. 

Treatment of Led Colic by Olive Oil, 311. 

Trional as a Hypnotic, 228. 

Tubercular Abscesses, 634. 

Typhoid Fever in Children, 427. 

Uremic Vomiting, 714. 

Vaginismus, 868. 

Varicose Ulcers, 515. 

Vesical Injections of Emulsions of Iodoform in 

Purulent Cystitis, 514. 
Vomiting in Pregnancy, 514. 
Wash for Pruritus, 428. 
Wax from Ear, to remove, 634. 
Worm Powders, 427. 
Worm Syrup, 427. 

Fracture of the Patella, 53-423. 

Of Scapula from Muscular Action, Hoover, 

P. V.. 848. 
Of the Thyroid Cartilage, 694. 
Frequency of Local Symptoms of Uterine Displace- 
ment, 356. 



Index. 



v 



Gall-Stones with Ulceration of the Gall Bladder into 

the Intestines, Currier, John M., 772. 
Gangrene of the Hand Consecutive to Influenza, 227, 

Following Fracture of Arm, 60. 
Gangrenous Intestine — Treatment of, 865. 
Gastro-Enterostomy — New Method, 274. 

Intestinal Catarrh in Children, Taylor, J. Madi- 
son, 837. 
Gastro-Intestinal Atony, 946. 
Glanders in the Horse, Clinical Study of, 70. 

In Man, 467. 
Glycerin Jelly for Mounting, 420. 
Gonorrheal Infection — Modes of Extension, 101. 

Rheumatism, Vance, A. M., 490. 
Gout in Child Eleven Years Old, 115. 
Grafting with Pigeon Skin, 788. 

Gravid Uterus, by Abdominal Section, removal of, 862. 
Growth of Bacteria through the Pasteur-Chamberland 
Filter, 268. 

Gynecology and the General Practitioner, Price, 
Joseph, 717. 

Clinic — Buffalo General Hospital, Man, Mathew 
D., 323. 

Technique, As Carried Out at the Gynecean 
Hospital, Baldy, J. M. 21. 

Hemorrhoids, 24-77. 

Hoffkine's Anti-Cholera Vaccines, Preparation of, 467. 

Head Injuries* with Aural Complications, 43. 

Heart Strain, Prophylaxis and Treatment, Stockton, 
Chas. G., 844. 

Heat in local Skin Diseases, 515. 

Hemorrhage from Stomach or Bowels, 169. 

Hepatic Insufficiency in Mental Disease — Heptic In- 
sanity, 185. 

Hernia Ischiatica, 669. 

Hip Disease, Treatment of 826. 

Hot water Bottles, Disadvantages of, 76. 

How to Treat those Overcome with Gas, 316. 

Hydatids of the Brain, 189. 

Hydrecephalus, 146. 

Hydrophobia, 395. 

Hypertrophied Floating Spleen; Splenectomy with re- 
covery, 226. 

Hypodermic Medication in Syphilis, Wolff, L., 525. 
Ichthyol in Gonorrhoea, 874. 

Icterus and Acute Atrophy of Liver following Syphi- 
lis, 783. 

Impacted Cerumen in Auditory Canal, Effects of, Cady, 
N. W., 444. 

Improvised Splints for Fractured Limbs in Cases of 

Emergency, Simpson, A. O., 534. 
Incipient Ischiatic Hernia, 550. 

Incisions in the Abdominal Walls, and Ventral Hernia, 

Treatment of, Ladd, G. D., 14. 
Individual Experience in the Treatment of Vesical 

Calculus, Ashhurst, John Jr., 920. 
Indications for Intubation, 754. 
Infantile Paralysis, 873. 
Infectious Erythemas, 181. 

Inflammation; Pus; Positively and Negatively Chemo- 
Lactic Substances, Cattell, Henry W., 48. 

Influence of Massage upon Rapidity of Absorption of 
Therapeutic Substances, 754. 

Inguinal Hernia and Epididymitis, 453. 

Innocents Abroad, Strickler, O. C, 383. 

Insurance Question, 57. 

Interesting Ovariotomies, McMurtry, L. S., 288. 
Intestinal Obstruction, 30 

Intravesical Injections or Etheral Solution of Iodoform 
in Oil, 873. 

Involution Forms of the Tubercle Bacillus and the 
Effect of Subcutaneous Injections of Organic Sub- 
stances on'Inflammation, Dixon, Samuel G., 317. 

Ipecac as an Oxytoxic and Parturifacient, T horn 
Jno. J., 447. 

Ipecacuanha in Uterine Inertia, Use of, 39. 



Ischio-Pubeotomy, or the Operation of Farabeuf, 144. 
Is it Catelepsy, Diurnal Epilepsy, Hysteria: Cerebral, 
Spinal, Functional or Organic, Justice, J. D., 448. 

Jaborandi in Hiccough, 115. 

Knee- Jerks in Supervenosity, 76. 

Laceration of the Cervix, 871. 

La Grippe or Epidemic Influenza, Results and 

Sequelae, Bergey, D. H., 770. 
Laparotomy performed on patients over seventy years 

old, 424. 
Laryngeal Intubation, 195. 
Lateral Dislocation of Elbow, 484. 
Leucocythemia; Appendicitis, 173. 

Leptothrix Mycosis of the Tonsil, Pharynx and Base 
of Tongue, with Report of three Cases, Cheatham, 
Wm., M. D., Louisville, Ky., 928. 

Life Insurance and its Relations to U. S. Pensioners, 
Stimpson, A. 0., Thompson, Pa., 926. 

LIBRARY TABLE— 

Allen etc., A Hand-book of Local Therapeutics, 949. 

Westphal, Contributions to the Knowledge of Pseudo- 
Leukemia, 950. 

Allen, Sam'l Ellsworth, M. D., The Mastoid Operation, 
672. 

Anderson, Winslow, M.D., Mineral Springs and Health 

Resorts of California, 472. 
Beach, B. S., M. D., Histology, Pathology and Physics, 
Bratenahl, G. W., Gynecology, 73. 
Brockway, F. J., M. D., Anatomy, 73. 
Bulkley, L. Duncan, A. M., M.D., Acne and Alopecia, 

73. 

Carmichael, James, M. D., Disease in Children, 312. 

Cerna, David, M. D., Ph. D., Notes on the Newer Rem- 
edies and their Therapeutic Applications, 73. 

Charcot, M. le Proff., Clinique des Maladies du Systeme 
Nerveux, 191. 

Charcot, Traites de Medicine, 191. 

Chetwood, C. A., M. D., Genito-Urinary and Venereal 
Diseases, 73. 

Dana, Charles L., A.M., M. D., Text Book of Nervous 
Diseases, 352. 

Dexter, Franklin, M. D,, The Anatomy of the Periton- 
eum, 312. 

Doubleday, E. T., M. D., Practice of Medicine, 73. 
Foster, Dr., Text-Book of Physiology, Part V., Appen- 
dix, 472. 

Gallandet, Bern.B., M. D., The Students Quiz Series, 
73. 

Gibson, George Alexander, M. D., Cheyne-Stokes Res- 
piration, 672.- 

Gimmel, Scarlet Fever in the Adult, 949. 

Hansel!, Howard F., M. D., Manual of Clinical Oph- 
thalmology, 150. 

Haynes, Irving S.. M. D., Guide to Dissection, 312. 

Hochaus, Contributions to the Pathology of the Heart, 
949. 

Hoyt, C. W., M. D., Obstetrics, 73. 

Hummel, A. L., M.D., Medical Journal Advertising, 151. 

Ingals, E. Fletcher, A.M., M.D., Diseases of the 

Chest, Throat, etc., 312. 
Killikelly, S. H., Curious Questions in History, etc., 151. 
Kirchhoff, Theodore, M. D., Hand-Book of Insanity, 

472. 

Kleen, Emil, M. D., Hand-Book of Massage, 233. 
Lydston, G. Frank, M.D., Gonorrhoea and Urethritis, 
73. 

McLaughlin, J. W., M.D., Fermentation, Infection and 

Immunity, 233. 
Manning, Frederick A., M.D., Physiology, 352. 
Manning, F. A., M. D., Physiology, 73. 
Mathews, Joseph M., M.D., Disease of the Rectum, 36. 
Miller, F. E,, M. D., Disease of Eye, Ear, Throat and 

Nose, 73. 



vi 



Index. 



Nuttall, George F., M.D., Ph.D , Hygienic Measures in 

Relation to Infectious Diseases, 35. 
Park, Davis & Co., Detroit, Mich., Price List, 472. 
Ransom, Charles C, M.D., Diseases of the Skin, 832. 
Rhodes, C. A., M. D., Diseases in Children, 73. 
Sands, R. A., M. D.. Surgery, 73. 
Schseffer, 0., M.D., Medical Pocket Atlases, 832. 
Seiler, Carl, M.D., Hand-Book of the Diagnosis and 

Treatment of Diseases of Throat, Nose, etc., 672. 
Startin, James, M. D., A Pharmacopseia for Diseases of 

the Skin, 832. 

Stephens, A. A., A. M., M. D., Manual of Practice of 
Medicine, 36. 

Sternberg, George M., M.D., Manual of Bacteriology, 
Stoel, Clinical Studies of Articular Rheumatism, 949. 
Struthers, J., Chemistry and Physics, 73. 
Swanzy, Henry R., A.M., M.B., F.R.C.S.I., Hand-Book 

of Diseases of the Eye, 149. 
Talamon, Ch., M. D., Appendicite et Perityphlite, 150. 
Transactions of the American Orthopoedic Association, 

Vol. V., published by Association, 472. 
Fuchs, Ernest, Dr., Text-Book of Ophthalmology, 232. 
Warner, L. F., M. D., Materia Medica and Therapeutics, 

73. • 

Wilson, George, M. D., Hand-Book of Hygiene and 

Sanitary Science,, 832. 
Ed. Ziemssen, H. V., M. D., Ed. Zenker, F. A. V., or 

Pub.Vogel, F.C.W., Deutches Archive fur Klinische 

Medicine, 233. 
Ziemssen, etc., Deutsche Archive fur. Clin. Med., 949. 

Ligation of the Anterior Tibal Artery above the Ankle 

Joint, Stimpson, A. 0., 131. 
Locomotor Ataxia, Townsend, E. H v 119. 
Lymphadenomae, Ingalls, E.Fletcher, 405. 

" Maison D'Accouchments Baudelogue," reportof 859 
Malarial Fever, Lambert, J. R., 437. 
Malignant Grippe, Burr, W. H., 
Management of Placenta in Delivery, 435. 
Management of Superation Complicating Tuberculous 
MDisease of Bones and Joints, Gibney, V. P. 240. 

astoid Disease and Brain Abscess, 217. 
Massachusetts Medical Journal, 950. 
Measuring Pelvis Outlet before Labor, 356. 
Medical Events, 351. 

Colleges and small cities, Link, Wm. H M D 
417. ' 
Medical Practice in Germany, 942. 
Metatarsalgia, 696. 

Metatarsalgia (Morton's Painful Affection of the Foot) 

Morton, Thomas, S. K., 723. 
Method of operating about the Face, by which little 

blood enters the mouth, 697. 
Methods and Material in Abdominal and Pelvic 

Surgery, Price, Joseph, 886. 
Micrococcus Lanceolatus, with special reference to the 

Etiology of Acute Labor Pneumonia, 268. 
Microcephalus, Operation, 900. 
Microbe Killer Defeated, 790. 
Missed Abortion, 155. 
Morphinism, Treatment of, 115. 

Motor Disturbances in Diseases of Children, Wilmarth 
A. W., 529. * 
Muscular Ruptures, 505. 

Multiple Fracture of both Upper Extremities, 695. 

Multiple Neuritis, Marechal, Edwin L., 637 

My FrstCase, 665. 

Myatomy during Pregnancy, 703. 

Nasal Douche, 555-715. 
Necrosis of Pubic Bone, 217. 
New Growth of the Umbilicus, 65. 
New Method of Staining the Capsule on the Pneu- 
monia Germ, 623. 
Neuralgia, 866. 

New York Letter, 138-222-260-300-339-384-419-462. 
New York State Medical Society, 223. 



Notes on Extra Uterine Pregnancy in the practice of 

Dr. Mordecai Price, Link, W. H., 600. 
Nursing in Typhoid Fever, Holmes, John C, 128. 



Object Lessons in Gynecology, Link, W. H., 41-157. 
Observations on the Therapeutic Treatment of Uterine 

Fibroids, Adams, Chas. W., 683. 
Official Surgery, 220. 

Operative procedure applicable to large Pus Tubes 

closely adherent to the Uterus, 504. 
Oophorectomy in Diseases of the Nervous System, 

Jones, Mary A. Dixon, 797. 
Ophthalmia Neonatorum and Hydrocele, 453. 
Otological Don'ts, Some, 864. 

Oui Dispensaries, Hospitals, Philanthropy, Frauds, 

and the Necessity of Medical Reform, 975. 
Ovarian Dermoid Tumors, 186. 
Ovarian Tumor, 332. 

Ovarian Cyst and Uterine Fibroid, Mann, M. A., 883. 



Pain and Insomnia, Treatment of, 227. 
Papulo-Squamous Syphiloderm, Shoemaker John V., 
205. 

Paraldehyde, 39, 754. 

Paralysis of Laryngeal Muscles, Cheatham, Wm., 486. 
Paralysis of Laryngeal Muscles, 494-486. 
Paranoia, Moyer, Harold N., and Lyman, Henry M., 
441. 

Parasitic Theory of the Etiology of Carcinoma, Park, 

Roswell, 237. 
Parasitic Origin of Cancer, 590. 

Passing a Sound through apparently impassible 
Stricture, 434. 

Pathologico-Anatomical changes in Tetanus Trau- 
matica, 347. 

Pathology of Carcinoma, 970. 

Pathology of Diabetes, 668. 

Pathology and Surgical Therapy of Chronic Diseases 

of the Coecum, 143. 
Pedicle in Abdominal Hysterectomy, Treatment of the, 

184. 

Pelvic Cellulitis, 608. 

Pelvic Disease, 219. 

Peptonuria in General Paralytics, 267. 

Perforative Shot Wound of Abdomen, 735. 

Periodical Intermenstrual Pains, 26. 

Periostical Sarcoma of the Jaw, 454. 

Peroxide of Hydrogen in Gastric Disturbances, 75. 

Peroxide of Hydrogen, 149. 

Personal Experiences in Operative Treatment of Rup- 
tured Tubal Pregnancy, 102. 

Pettenkofer's Personal Experiments with Cholera 
Germ, 591. 

Philadelphia — The Medical and Surgical Centre of 

America, Carpenter, J. G., 585. 
Phimosis and Circumcision, 195. 

Physical Import of "Variable Achromatopsia, Purdon, 

John Edward., 200. 
Physiology of the Heart, 620. 

Physiological Action of Massage upon Human Muscle, 

676. 
Piperazin, 433. 
Placenta Praevia, 108. 
Plain words on Glaucoma, 390. 
Pleurisy, Treatment of, 440. 
Pneumonia: Gall-stones, Robison, John A., 287. 
Points of Similarity between Us and Homoeopathic 

Physicians, Roberts, John B., 813. 
Poisoned by Strychnine, 432. 

Portable Combined Optometer and Opthalmoscope 
(Opthalmometroscope), Moon, Ropert C, 212. 
Position of Strontium in Therapeutics, Shoemaker, 

John V., 757. 
Post-Operative Intestinal Obstructions, 27. 
Post-Partum Hemorrhage, Treatment of, 196. 
Postural Pathology and Therapeutics in Obstetrics and 

Gynecology, Dewees, William B., 558. 



Index. 



vii 



Pott's Disease, Edmonson, M. M., 248, 
Poultices, 77. 

Practical Hints on Administration of Medicines, or 
Application of Remedies, 785. 

Pregnancy and Ovarian Tumor, 499. 

Preliminary Communication Concerning the Antisep- 
tic Value of Phenocoll Hydrochloride, 830. 

Present Position of Gail-Bladder Surgery, 755. 

Present Status of Urethral Surgery, Palmer, E. R., 329. 

Present Status of Corrosive Sublimate in Surgery, 
Vance, Ap. Morgan, 532. 

Preventable Deaths of Child-Birth, Terry, Herbert, 357. 

Preventive and Curative Drinks and Medicines, 137. 

Prevention and Cure of Puerperal Sepsis, 78. 

Professor Liebreich on Mineral Waters, 867. 

Prolapse of the Womb — Prom Hyperthropic Elonga- 
tion of the Super-Vaginal Portion of the Cervix — 
Supernumerary Ovary with Ventral Hernia — Pyo- 
Salpingitis — Nervous Ovaries, Goodell, William, 163. 

Prolapsus Vaginal, 457. 

Proteolytic Action of Papoid, 705. 

Puerperal Eclampsia, 392. 

Puerperal Cases of the Munchener Frauenklinik, 1877- 
91-422. 

Purification of Drinking Water by Sand Infiltration, 
704. 

Pulmonary Hemorrhage, 269. 
Pyosalpinx, 217. 



Quinine in Treatment of Wounds, 595. 
Quinine Pill-Mass, 682. 
Quinine Tannate, 432. 



Radical Cure of Femoral Hernia, 116. 

Rapid Method of Locating Intestinal Wounds, 596. 

Rapid Operative Procedure as a Means of Reducing the 

Mortality in Abdominal and Pelvic Surgery, Cordier, 

A. H., 677. 

Radical Operation for Umbilical Hernia, 267. 

Rare Case of Injury during Labor, 423. 

Rational Treatment of Puerperal Septic Infection, 262. 

Recurrent Earache, 348. 

Reflex Disturbances in the Causation of Epilepsy, 

Krause, William C, 208. 
Relation of Albuminuria to Surgical Operations, 194. 
Relation of Pelvic Disease and Psychical Disturbances 

in Women, 230. 
Relation of Rheumatism and Chorea, 145. 
Removal of Appendix, Death from Uraemia, 53. 
Removal of Goitre, 507. 
Remedial Use of Apples, 25. 

Report of all Laparotomies Performed in the Clinics of 
Prof. Billroth during the last 25 years, 506. 

Reproduction of Printed Matter, 416. 

Report of a Case of Detachment of the Ligament of 
the Patella — Treatment by Suture. Recovery, 961. 

Resection of Left Lobe of Liver for Cancer, 28. 

Rest vs. Exercise in the Treatment of Pulmonary 
Consumption, Mays, Thomas J., 915. 

Retardation of Brain Development; Gastralgia; Defec- 
tive Nutrition; Loss of Memory, Lyman, Henry M., 
481. 

Retention Cysts of the tubes, Treatment of, by Dilata- 
tion of Uterus, 466. 

Revival of " Heatonism; " Hernial Institutes and Sub- 
cutaneous, Injection for Hernia Veritas, 95. 

Rheumatism, Russell, F. H., 251. 

Right Hemiplegia and Aphasia, Following Diphtheria 

in a Child, 114. 
Ringworm, Treatment of, 139. 

Rupture of the Billiary Passages in Contusion of the 

Abdomen, 549. 
Rupture of Pelvic Abscess, 604. 
Rupture of the Uterus, 142. 

Rupture of the Uterus Following Administration of 

Ergot, Sutherland, H. H., 491. 
Sacral Operations, 909. 



Sarcoma — Arthritis Deformans ; Cicatrix following 
Burn ; Morabus Coxarius, Park, Roswell, 360. 

Of the Breast at the age of sixteen years : 

Ovarian Cyst, Cartledge, A. M., 88. 
Of the Jaw, Iodoform poisoning, 455. 
Saturnine, Encephalopathy, 309. 
Salicylate of Bismuth in Infentile Diarrhoea, 595. 
Salient points in Appendicitis, its Diagnosis and Treat- 
ment. Hoffman, Joseph, 160. 
Salol, 39. 

Salycilates in Treatment of Pleurisy with Effusion, 
676. 

Scarlet Fever, 714. 

Senile and Secondary Cataracts and their Treatment, 
Jackson, Edward, 521. 

Sexual Function and Insanity, Price, Joseph, (Mono- 
graph series, No. 1.), 1. 

Significance of Vaginal Discharges. 

Signs of Shock, 629. 

Simplication of Therapeutics, 75. 

Sleep and its disturbances in Children, 747. 

SOCIETY REPORTS— 

American Surgical Association, 938. 

Clinical Society of Louisville, 59-171-298-412, 492-580 
604-849. 

Georgia State Medical Association, 773. 

Jefferson County (Ky.) Medical Society, 689. 

Medico-Chirurgical Society of Louisville, 90-254-332- 
368-540-821. 

Medico Chirurgical Society of Louisville, 897. 

Milwaukee Medical Society, 17. 

Philadelphia Academy of Surgery, 691. 

Philadelphia County Medical Society, 535-661. 

Surgical Society of Louisville, 53-133-216-292 499-735 . 

Western Association of Obstetricians and Gynecolo- 
gists, 371-457-496-610. 

Some Reports of the Epidemic of Cholera of 1892 in 
City Hospitals of Altoona, Prussia, Herbst, A., 891. 
Spasmodic Stricture of Oesophagus, 494. 
Spastic Paralysis from Central Lesion, 412. 
Special Influence of Alcohol on the Body. 
Specific Urethritis in Children, 109. 

Vaginitis, Cecil, John G., 410. 

Spontaneous Cure of Rupture of the Uterus, 196. 

Squamous Eczema, 456. 
Statistical study of Mortality from Anaesthetics, 715. 
Statistics on Anaesthesia, 829. 
Strangulated Femoral Hernia, 449. 
Sterility following Gonorrhoea, 133. 
Story of the Insane, 69. 
Stricture of the Oesophagus, 216-851. 

Of Rectum, 298. 

Of the Rectum, Mathews, J. M., 290. 
Of the Tear Duct, 582. 
Of the Urethra, 219. 
Study of Fish Poisons, 185. 
Strychnine and Digitalis in Diarrhoea, 273. 

As Remedy and Prevention of Surgical Shock, 
Anaesthetic Collapse and Opium Poisoning, 
153. 

Versus Ergot in Obstetric Practice, Hall, G. V., 
732. 

Subcutaneous Injection of Fowler's Solution, 184. 

Injections of Normal Nerve Substance in Epi- 
lepsy and Neurasthenia, 272. 
Substances Incompatible with Antipyrine, 272. 
Suckling and Quinine, 155. 

Summary of Results in Treatment of 701 cases of 
Membraneous Laryngitis by Intubation, 742. 

Suppurating Buboes, Injections of Iodoform Oint- 
ment in Treatment of, 789. 

Suppurative Intra-Pelvic Inflammation with Speci- 
mens, McMurtry, L. S., 170. 

Suppuration of Parotid Gland, 540. 

Surgery of the Billiary Passages, 346. 
Of the Gall-Bladder, 185-346. 

Surgical Measures of Relief in Stenosis of the Upper 
Air Passages, Manley, Thomas H., 284. 



viii 



Index. 



Surgical Treatment of Epilepsy, 350. 

Treatment of Stenosis of the Pylorus, 229 . 

Therapy of Rectal Cancer, 508. 
Suicides of Children in Germany, 910. 
Suture of Tendons, Crandall, Dr. John B., Sterling, 

Illinois, 925. 
Suture Applied to Wounds of Veins, 516. 
Suturing of Divided Tendons, 649. 
Symes, (W. L.) on Hicough, 555. 
Symphyseotomy in Man, 434. 
Symptoms of Hip-Joint Disease, 715. 
Syphilis and Typhoid Fever, 583. 
Syphilis and Wounds, 873. 



Talipes, Fracture of Acromial End of Clavicle, Double 
Fracture of Shaft of Femur, Hare-Lip, Park, Bos- 
well, 83. 

Technique of Supra-Pubic Cystotomy, Chenoweth, 

Jas. S., 126. 
Tendon Reflexes, 114. 

That Unfortunate " Conservative," Towler, S. S., 338. 

The Advance Guard, Burr, W. H., 261. 

The Law of Criminal Abortion in Pennsylvania, Bul- 

ette, Lorenzo D., 650. 
Tetanus — Treatment of, 66. 
Tetany as Sequela of Puerperal Eclampsia, 426. 

In Children, 715. 
Theory of the Phagocytes, 265. 
The American Gynecological Journal, 951. 
The Chicago Medical Recorder, 952. 
The Relations of Operative Gynecology to Insanity, 

948. . 

The Surgery of Childhood, 975. 

The Virginia Medical Monthly, 980. 

The American Journal of the Medical Sciences, 982. 

Thiol in Treatment of Burns, 96. 

Thoughts on General Anaesthesia, — Treatment of 
Accidents of Anaesthesia, Burr, Wm. H., 397. 

Total Exterpation of Uterus per Vagina in Malignant 
Disease, 184. 

Toxicity of Urine of Patients with Suppurative 

Affections, 676. 
Transplantation of Bone, 274. 

Treatment of Biliary Colic with Glycerine, Geyer, H. 

Reasoner, 488. 
Treatment of Hemorrhoids, Pryor, Jas. E., 603; 



Treatment of Inguinal Hernia, Dallas, Alex., 277. 
Tropho-Neuroses, Associated with Abnormality of the 

Thyroid Gland, 469. 
Tubercle Bacilli in Lymphatic Glands of Non-Tuburcu- 

lous Persons, 591. 
Tuberculosis of Intestine with Black Urine, 229. 

Of Shoulder Joint ; Tonsillotomy ; Tuberculosis 
of Hip-Joint, Hamilton, John B., 122. 
Tuberculous Ulcers of Stomach, 40. 
Tuberculous Knee-Joint, Amputation, 898. 
Tumor of the Breast, 849. 
Twin Pregnancy, 489. 

Two Cases of Malignant Diphtheria, Butler, Frank P., 
602. 



Unusual Case of Retained Placenta, Van Eman, J. H., 

M.D., 408.. 
Urgent Operations in Obstetrics, 306. 
Urticaria, 90. 

And Death After Ovariotomy, 435. 
Use and Abuse of Trusses, Vance, Ap. Morgan, 687. 
Use of Anaesthetics in Obstetrics, 229. 
Use of Cocaine, The, 196. 

Use of Thiersch's Skin-grafts as substitute for Con- 
junctiva, 914. 
Uterine Polyp, 897. 

Uterine Fungosities, Schooler, Lewis, 571. 
Vaginal Hysterectomy for Cancer, 147. 
Varicocele, 255. 

In Women, 795. 
Veratrum Viride in Scarlet Fever, 109. 
Veritas, 95. 

Vermiform Appendix Containing a Foreign Body, 

Found in a Hernia, 102. 
Viability of Cholera Bacillus on Various Food Stuffs, 

etc., 623. 
Vibratory Medication, 187. 
Vomiting in Pregnancy, 676. 
Vulvitus with "Gonorrhoeal Rheumatism," 196. 

Watson (Francis Sedwick) on Treatment of Bubo, 755. 
What is the Sphere of the Nasal Spray ? Evans, T. C, 
573. 

Who Owns the Prescription ? 39. 
Why Good Swimmers Drown, 763, 
Why Should I Not Use the Forceps, 107. 



Vol. LXVIII, No. 1. 
Whole No. 1871. 



JANUARY 7, 1893 



$5.00 per Annum 
10 Cents a Copy 



A WEEKLY JOURNAL. 



Established 1853, by S. W. Butler, M.D. 



THE 2 5609^) 

MEDICAL AND SURGICAL 
REPORTER 



Entered as Second=Class Matter at Philadelphia P. O. 



P. O. BOX 843, PHILA, PA. 



ORIGINAL ARTICLES. 

A. H. Cordier, M. D., Kansas City, Mo. 

A Plea for the Early Treatment of Appendicitis . . 1 
A. Lapthorn Smith, B. A., M. D., M. R. O. S.. England. 

Some Successes and Failures with Electricity in 
Gynecology 6 

CLINICAL LECTURES. 

E. E. Montgomery, Philadelphia. 
Carcinoma Uteri . 



10 



COMMUNICATIONS. 

I G. D. Todd, M. D., Milwaukee, Wis. 

The Treatment of Incisions in the Abdominal Walls, 

and Ventral Hernia 14 

H. G. Norton, M. D., Trenton, N. J. 
I The Aseptic and Anti-Septic care of the Lying-in 

Woman and New-born Child 16 

SOCIETY REPORTS. 

I The Milwaukee Medical Society 17 

I Philadelphia County Medical Society — Gynecological 
Technique as carried out at the Gynecean Hospital 21 



EDITORIAL 

TRANSLATIONS . . . 

ABSTRACTS 

THE LIBRARY TABLE 



CURRENT LITERATURE REVIEWED 



PERISCOPE 

THERAPEUTICS 
MEDICINE . . 



NEWS AND MISCELLANY 
ARMY AND NAVY . 



NO OPENERS 

FOR CHAMPAGNE REQUIRED. 



By means of a small seal attached to wire, the latter can be 
broken and easily removed by hand, together with top of cap, 
on G. H. MUMM & CO.'S Extra Dry. 

G. H. Mumm & Co. having bought immense quantities of the 
choicest growths of the excellent 1884, 1887 and 1889 vintages, 
the remarkable quality and delicious dryness of their Extra Dry 
can be relied upon for years to come. 

• ' By chemical analysis the purest and most wholesome cham- 
pagne." — R. Ogden Dorb mtjs, M. D., LL.D,, 

Professor of Chemistry, N. Y. 




The Demand For 

a pleasant and effective liquid laxative has long exi 
laxative that would be entirely safe for physicians to presci 
for patients of all ages — even the very young, the very old, 
the pregnant woman and the invalid — such a laxative as 
the physician could sanction for family use because its 
constituents were known to the profession and the remedy 
itself had been proven to be prompt and reliable in its action, 
as well as pleasant to administer and never followed by the 
slightest debilitation. After a careful study of the means to 
be employed to produce such 

A Perfect foaxative 



the' California Fig Syrup Company manufactured, from the 
juice of True Alexandria Senna and an excellent combina- 
tion of carminative aromatics with pure white sugar, the 
laxative which is now so well and favorably known under the trade name of " Syrup of Figs." 
With the exceptional facilities, resulting from long experience and entire devotion to the one 
purpose of making our product unequalled, this demand for the perfect laxative 



is met by Our /Vl^thod 



of extracting the laxative properties of Senna without retaining the griping principle found 
in all other preparations or combinations of this drug. This method is known only to us, 
and all efforts to produce cheap imitations or substitutes may result in injury to a physician's 
reputation, and will give dissatisfaction to the patient ; hence, we trust that when physicians recom- 
mend or prescribe "Syrup of Figs ,y (Syr. Fici Cal.) 'they will not permit any substitution. The 
name "Syrup of Figs" was given to this laxative, not because in the process 



of /Manufacturing 



a few figs are used, but to distinguish it from all other laxatives, and the United States Courts 
have decided that we have the exclusive right to apply this name to a laxative medicine. The 
dose of 



"SVRUP OF FIGS" 



as a laxative is one or two teaspoonfuls given preferably before breakfast or at bed time. From 
one-half to One tablespoonful acts as a purgative, and may be 'repeated in six hours if necessary, 
" Syrup of Figs " is never sold in bulk. It is put up in two sizes to retail at fifty cents and $1.00 per 
bottle, and the name "Syrup of Figs" as well as the name of the California Fig Syrup Company is 
printed on the wrappers and labels of every bottle. 

CALIFORNIA FIG SYRUP COMPANY 

SAN FRANCISCO, CAL. 
LOUISVILLE, KY. NEW YORK, N. Y. 



THE 

MEDICAL AND SURGICAL 
REPORTER. 

No. 1871. PHILADELPHIA, JANUARY 7, 1893. Vol. LXVIII— No. 1 

ORIGINAL ARTICLES. 

A PLEA FOR THE EARLY SURGICAL TREATMENT OF APPENDICITIS. * 

A. H. CORDIER, M. D., Kansas City, Mo.f 



In selecting this important topic to 
write on, I am imbued with a desire not 
only to bring before this society my views, 
bat to elicit a discussion as well, that the 
deductions may be compared with my ob- 
servations, experience and understanding 
of the pathological history of, and the sur- 
gical procedure in the treatment of this 
frequent and dangerous affection. I am 
of the opinion that my statements will meet 
with a strong and vigorous opposition from 
some of the very best practitioners present, 
whose error (according to my opinion) is 
a mistake in the interpretation of the 
exact etiology and pathology of the dis- 
ease, and not engendered by a desire to 
oppose progress or to bar the surgical re- 
lief of these cases. 

All students of medicine and surgery 
have equal opportunities, in so far as the 
literature on this topic is concerned, to be- 
come familiar with its history and pro- 
gress, and it is true in this case as in many 
others of a like character, that our utter- 
ances are along the line of the teachings 
of books we have consulted, added to per- 
sonal experience. 

You will find the author or teacher of 
theory and practice of medicine, holding 
what he terms a conservative position on all 
subjects classified as surgical. For in- 
stance, the hemorrhoid has an ointment 
applied, the osteomyelitic tibia has a lini- 

fRead before Kansas City District Medical Society, 
Dec. 8, 1892. 

"* Member of American Medical Association, Member 
of American Association Obstetrician, Corresponding 
Member of Philadelphia Obstetrical Society, etc.. etc. 



ment and hot fomentations for weeks, 
while the disease with rapid strides gains 
ground and undermines the general physi- 
cal condition of the patient. 

From a surgical standpoint, we have 
men who are so desirous of tabulating a vast 
number of surgical cases, that the patient 
has only to diagnose his hemorrhoid, her 
cystic (?) ovary, or the presence of a phan- 
tom tumor, to press the button and the sur- 
geon will do the rest. While these decla- 
rations are a little overdrawn, both from 
a medical and surgical view, yet it is only by 
a difference in degree and not in kind that 
they can be called exaggerations. We 
have a medium in all things, both medi- 
cal and surgical, appendicitis and a few 
other rapidly death producing and recurr- 
ing processes, excepted. 

The location and tendency of a disease 
should place the radical or conservative 
stamp on the procedure for the relief or 
cure of the same. A hemorrhage from a 
small meningeal vessel may cause death 
speedily, if not immediately controlled 
by rational surgical procedure. A bleed- 
ing from the nose would be passed by as a 
trivial affair, requiring no farther treat- 
ment than that of conservatism — let it 
alone and it will stop of itself. 

I imagine that my position is now 
understood and that some of my friends 
present are " laying" for me. 

I have heard the subject of appendicitis 
discussed by the most learned body of 
medical and surgical gentlemen ever as- 
sembled in this country — where such men 
as Bryant and McCormack, of London, 



2 



Original Articles. 



Vol. lxviii 



Agnew, Price, Keen, Morton and As- 
hurst, discussed the subject from a surgical 
standpoint, while Da Oosta, Pepper and 
others, spoke from the medical side. 
While these great surgeons with a vast ex- 
perience, as a unit, endorsed early operative 
interference, the equally celebrated medi- 
cal gentlemen advised delays and tinker- 
ing, but all agreed that the disease was 
one attended with much danger, with a 
tendency to return, and that many of the 
casi-s required operative procedure for its 
relief or cure. 

I shall dwell upon the anatomy of this 
part of our make up, only to call attention 
to the fact that the caecum and the appen- 
dix have a peritoneal covering. At the 
same time, I want to disabuse your minds 
(if any so believing are present) of the 
possibility of doing an operation for ap- 
pendicitis extra peritoneally . 

The appendix has only a slight vermi- 
cular movement to expel or dislodge any 
substance once in its cavity. Post-mor- 
tem examinations and surgical operations 
have demonstrated that with very rare 
exceptions (traumatic, typhoid, tubercu- 
lar, neoplastic) inflammations occurring 
about the head of the colon are, primarily, of 
appendicular origin, and that the exciting 
cause was some foreign body lodged in this 
f unctionless and dangerous rudimentary ap- 
pendage. It is the experience of surgeons 
that the disease is of caecal origin once only, 
in every one-hundred and fifty cases, so we 
can safely eliminate from the diagnosis or 
co aside ration of the pathology these ex- 
ceptions by their extreme infrequency and 
by the fact that they demand the same 
surgical procedure up to the point of 
establishing a positive diagnosis. 

A few years ago " inflammation of the 
bowels," so-called, was of frequent occur- 
rence, and "idiopathic peritonitis" was 
not rare, the causes of both being a mys- 
tery unexplained up to the beginning of 
the true history of appendicitis and sal- 
pingitis. Since the pathology of these 
two intra-peritoneal diseases has been cor- 
rectly understood " pelvic cellulitis" and 
"inflammation of the bowels " ; are terms 
rapidly disappearing from our medical and 
surgical nomenclature. 

A body (grape, orange or cherry seed) 
having onoe entered the appendix, let us 
see what takes place. The foreign body 
is there to stay, unless by accident it es- 
capes, as -this tube has not the power to 



expel it. A cherry-stone in close confine- 
ment in the narrow prison, surrounded by 
moisture and warmth soon settles down to 
business, and, as a result of its presence 
and pressure, an ulcer forms beneath 
it. As this approaches the serous cover- 
ing, the ever-present pathogenic bacteria 
find an avenue of escape and swarm to- 
ward the peritoneum. The peritoneum 
with its endothelial covering, and the 
phagocytes at once begin an active war- 
fare with the intruders (Metschnikoff). 
Breastworks are built up from the dead of 
the conflict, and the war goes on or, for 
the time, peace is declared, according to 
which force is the stronger. 

Now, while this is taking place within 
the iliac fossa, the unfortunate victim is 
having a temperature from 96° F. to 105° 
F. according to the extent of peritonitis, 
amount of septic absorption, or intensity 
of the shock following a perforation. 
The breastwork is nothing more or less 
than an effort on the part of nature to 
wall-ofl and limit the destructive process 
that is threatening the general peritoneal 
cavity. 

The patient has a constipated bowel 
from two causes, one from a drying-up or 
a checking of the intestinal-juices, and 
want of peristalsis — too frequently as a re- 
sult of large and repeated doses of opium 
for the relief of the pain. He will have 
more or less tenderness in this locality, 
diffused or circumscribed according to 
the extent of the inflammatory processes 
within. McBurney's point is painful on 
deep pressure in most cases, the excep- 
tions hieing where the appendix is not in 
its usual location. If the disease is very 
far advanced (I mean if the inflammatory 
deposits are at all extensive), you will be 
enabled to map out a well-marked dull- 
ness. 

Your patient will go from bad to worse 
in this stage of the disease, or, his fever 
may subside, his pain in part disappear 
(tenderness on deep pressure will remain), 
appetite return, bowels become regular and 
he may be, so far as his general appearance 
goes, in good health. 

Now let me picture to you his local con- 
dition: Nature has for the time being 
built up a barrier, that holds the disease 
in check, but this fortification, you must 
remember, has within its walls the original 
source of the trouble, — it may be a fascal 
concretion, a grape, or an orange seed. 



January 7, 1893. Original Articles. 



3 



He is in danger of a relapse at any 
time; and each time the disease is started 
up anew, there is added fresh complica- 
tions, the danger is increased and the like- 
lihood of your surgery being successful di- 
minished. His next attack may prove fatal. 

The diagnosis and the history of this 
disease is so thoroughly understood by all 
that it would be useless to dwell further 
on this point. 

In the matter of pathology and treat- 
ment, I am sorry to say, there is a want of 
unanimity in the profession that too often 
leads to dangerous delay in resorting to 
surgical procedures for the speedy relief of 
this condition. 

The medical treatment I will sum up in 
a few words. Of much import is the mini- 
mum of time in following out the medical 
course. Salines, in good full doses, are in- 
dicated above all other remedies, as the 
watery action produced by the salts is a 
good preparation for the surgery that 
must follow. All opium should be 
avoided, as it masks the symptoms and 
places the patient in a bad condition for an 
abdominal operation. Oodeia, etc., etc., 
may be tried. Blistering does no good, 
besides leaving an infected surface to cut 
through. Indeed any case with symptoms 
so severe as to require a blister is grave 
enough to demand coeJiotomy. Hot 
applications add to the comfort of 
the patient but produce an oedematous 
condition of the abdominal walls and do 
not add to the chances of recovery. This 
oedema may mislead the surgeon as it 
gives a sense of fluctuation on exam- 
ination. Large warm water enemata, to 
which is added a teaspoonf ul of turpentine, 
will empty the colon of feces and gas, and 
thereby make the patient more comfort- 
able. 

The technique of the surgical procedure 
must of necessity be such as to fulfill the in- 
dications in individual cases. In one 
case the appendix will have to be ligated 
and removed ; in another the appendix may 
be found lying loose in an abscess cavity, 
having sloughed at its junction with the 
csecum. Again you may find the appen- 
dix bound up in a mass of adhesions — the 
condition often found in delayed or re- 
lapsing cases. 

No major operation in surgery, where it 
is performed early, has a lower death rate ; 
and no capital surgical procedure has a 
higher mortality following it than this, if 



postponed beyond the safe period for 
operation. I say following the operation 
because the deaths following the operation 
are due, in most instances, to the fact that 
the patient is dying at the time the opera- 
tion is performed. You cannot rescue a 
patient suffering with a diffused septic 
peritonitis, with faecal matter or other sep- 
tic material (pus) all over the omentum, 
mesentery and diaphragm. 

Gentlemen you must operate early on 
these cases and your results will be at- 
tended with an almost nil mortality. I 
believe the position taken by Prof. Keen 
is a correct one, when he declares, that 
the physician and the surgeon should see 
the case together right along from the day 
the symptoms point to an attack of appen- 
dicitis. 

If your patient does not improve in a 
few days (say three at farthest) under 
salines, restricted diet, etc., etc., I would 
advise resort to operation. Some cases 
die within a shorter period following the 
first manifested symptoms of the disease. 
Operate at once. Do not delay an hour. 
If the bowels do not move from the effects 
of the salines and the symptoms persist, 
even though mild, operate at once. A 
constipated bowel is always a bad symptom 
in this disease even though other symp- 
toms point to a mild attack. If in relap- 
sing cases (old abscesses) there is an indi- 
cation of septic absorption, we have 
special reason for immediate operation. 
Cases should be operated on before a sep- 
tic condition is developed. We should 
operate in children as soon as possible, for 
the disease makes quicker inroads in the 
young than in the adult. 

I desire to lay stress upon the fact that 
the heighth of the temperature and the 
severity of the pain in these cases cannot 
be used as guides to point out the indica- 
tions for or against an operation. The 
temperature may be, and in fact often is, 
subnormal, especially in the acute perfor- 
ative cases. The pain is often masked by 
large doses of opium. 

If you decide to wait at the solicitation 
of the patient or of the family, watch 
closely for the advent of alarming symp- 
toms and insist on an operation the mo- 
ment such are observed. I do not advise 
procrastination but we must consult the 
wishes of the patient and abide by his 
decision, even against our own better 
judgment. 



4 



Original Articles. 



Vol. lxviii 



The surgeon who undertakes abdominal 
work should be familiar with all the com- 
plications liable to be met with in this 
locality, and quick in his dealings with the 
same. " The disease may have produced 
such wide- spread death of the intestines 
that an extensive resection and anastomo- 
sis may be necessary. 

Unless the surgeon has by constant 
study, experimental work and operative 
experience made himself acquainted with 
all these details he will find his inventive 
resources taxed to the uttermost to meet 
unlooked for complications. 

The diagnosis of inflammatory disease 
at the head of the colon by the painstak- 
ing general practitioner, in the great ma- 
jority of instances, will be found to be 
correct and the only point of disagree- 
ment with the surgeon will be the patho- 
logy and, occasionally, the propriety of sur- 
gical treatment. This disagreement will 
persist so long as there exists a division 
of opinion on the point of origin of the 
disease, that is — did the disease -originate 
in the appendix and extend to the cascal 
region, or is it primarily of ccecal origin? 
Gentleman, I assure you, it will be safe to 
say the appendix every time. 

I briefly report a few cases that it has 
been my lot to observe, either in consul- 
tation or as attending physician. I desire 
to preface the reports by the confession, 
that my management of some of the 
earlier cases now meets with my strongest 
condemnation, and as I recall these facts 
it is with a feeling almost akin to that of 
criminal negligence or unpardonable sur- 
gical timidity. 

Case I. Miss B., age 20; German. 
This young lady was taken sick Feb. 28, 
188T. Had a severe chill. Had a pain 
in right iliac fossa radiating into the right 
lumbar region. This pain is paroxysmal 
in character but she has pain all the time 
(this is a diagnostic symptom in excluding 
colic and other non-inflammatory diseases. ) 
Has been vomiting a greenish, sour-smell- 
ing material, is sweating profusely (a bad 
symptom,) temperature 100, pulse 120. 
Bowels have not acted since 25th. (a con- 
stipated bowel is also an unfavorable symp- 
tom.) Pain on pressure over csecum. 
Dullness on percussion (this is the fifth 
day since she first complained, and the 
first time I saw the case.) Has had in- 
fusion of senna with no results. I sug- 
gested an operation if improvement did not 



begin soon, (I should have said operate at 
once) at same time prescribed large doses 
of morphine. (This I now recognize as an 
agent to mask the symptoms and result 
in bringing about a false feeling of se- 
curity in the mind of the patient and the 
family, and even to put a staying hand on 
the better judgement of the surgeon and 
thus cause him to delay intelligent surgery 
which is too often responsible for the loss 
of valuable lives. ) At my next visit I found 
her as she expressed it "feeling better." 
March 8, or ten days since the beginning 
of the attack, I find her much worse. 
On the night of March 10, she was taken 
with a most unbearable pain in the region 
of appendix, followed by profound shock 
(perforation of abscess wall and escape of 
pus into general peritoneal cavity). She 
died a few hours later. 

This young lady to-day, gentlemen, 
would be living in so far as this attack 
was concerned had she received the benefit 
of good, timely surgery. I have since 
operated early on very similar cases and 
saved them. 

Case II. April 5, 1889. I saw this 
case in consultation. Mrs. L., aged thirty- 
four; mother. Three days before I saw 
this lady, she was taken with a chill (she 
had been feeling badly for several days), 
the temperature soon ran up to 105° F. 
(due to rapid absorption of septic material). 
She has great pain in caecal region, tender- 
ness localized. Bowels acted from effects 
of a dose of Epsom salts administered the 
day before. This was good treatment. 
An obscure sense of deep fluctuation is 
discoverable. Peculiar facial expression, 
seen in patients suffering with peritonitis 
or marked shock. I advised an operation at 
once, but my proposition met with a square 
and obstinate opposition from the uncle 
who had charge of the case. This was 
the last time I saw the case. Fifteen hours 
before her death she developed synrptoms 
indicative of perforation, the shock fol- 
lowing lasted up to her death. No one, 
I trust, will question the propriety of 
urging early operations in like cases. Any 
case, even the mildest, may quickly assume 
this dangerous character. 

Case III. This case was reported soon 
after its occurrence, as a case illustrating 
the position taken by some writers, even 
at this date (I was of same opinion at that 
time), that faecal impaction is a frequent 
cause of inflammatory processes in this 



January 7, 1893. 



Original Articles. 



5 



locality. The post-mortem a few mouths 
later revealed a cancer of the caecum. 

Mrs. H., age 30, mother. I saw this 
case in consultation. For some time she 
had noticed an enlargement in region of 
caecum, movable, painless and doughy (?) 
to touch. Has had colic pains for a month, 
constipation alternating with diarrhoea. 
Temperature 108° pulse 124. Some 
pain in abdomen. I diagnosed the case as 
one of faecal impaction of caecum, with a 
mild attack of perityphlitis. I saw her a 
week later and found her ' 'about the same. " 
Entered in my record book at this time, 
" This is one of the cases of perityphlitis 
in which a delay of surgical procedure is 
not only justified but desirable." 

Case IV. Willie K., age 20, male. 
November 20, 1892. I was called to see 
this young man in consultation with Dr. 
Smoit, of Nickerson, Kansas. The doctor 
had diagnosed the case correctly and in- 
sisted on early operation, but owing to the 
the fact that the patient's parents lived in 
Buffalo, N. Y., some valuable time was 
lost in getting the father's consent. At 
the time I operated, the temperature was 
96.5° F., (please note this fact, as a high 
temperature does not necessarily accom- 
pany the worst form of the disease). His 
pulse was 55. He was hiccoughing and 
vomiting frequently, countenance pinched, 
cold, clammy perspiration all over the body. 
In fact, his condition was one, the outlook 
of which was certainly very unfavorable. 
Without an operation death was near at 
hand . 

The operation was quickly performed, 
only twenty minutes of ancesthesia. An 
inflammatory mass as large as the closed 
hand was found surrounding a diseased 
and perforated appendix. A cherry stone 
was lying loose in the abscess cavity. A 
perforation at the junction of the appen- 
dix to the caecum was found and left open; 
no attempt to remove the appendix was 
made. The abscess cavity was carefully 
irrigated and cleansed with peroxide of 
hydrogen, a rubber drainage tube intro- 
duced surrounded with iodoform gauze; 
a large opening was left through which 
the contents of abscess might escape. 

While this operation was not an ideal 
one in its completeness, it was certainly 
good surgery as the results in the case 
show. The young man to-day is up and 
about his room. The appendix will prob- 
ably atrophy, the inn unmatory mass will 



in a great measure, be absorbed, and that 
locality will in all probility cease to give 
him further trouble. Should it threaten 
him with another attack, an early opera- 
tion, before he is in the very grasp of 
death, shouid be performed and the mass 
broken up or the appendix removed. I 
do not think this will be necessary. 

I submit to you for discussion, the fol- 
lowing deductions: 

1st. This is a disease of frequent oc- 
currence and one attended with much 
danger. 

2d. The disease primarily located in 
the appendix, may exist for months 
or years in a semi-latent state before well- 
marked or alarming symptoms develop. 

3d. That inflammatory diseases located 
about the head of the colon, in the great 
majority of cases, owe their origin to a 
diseased, ulcerated or perforated appendix. 

4th. The percentage of death from this 
disease will continue to diminish in pro- 
portion to the correct understanding of the 
pathology and the recognition of the neces- 
sitv of early surgical relief being resorted 
to. 

5th. All recurring and all well- 
marked cases of appendicitis should 
be operated on at once. This applies 
with special force to patients who have had 
a number of attacks and are contemplating 
a journey to localities where skilled sur- 
gical aid can not be quickly obtained. 



When the soft tissues are crushed and 
the surgeon is in doubt where to operate, 
and waits for the line of demarkation to 
form, poultices should not be used, for 
they sodden and thus weaken the tissues. 
Hot water should be applied every hour 
for five to ten minutes at a time, and dur- 
ing the interval the part should be wrapped 
in hot dry cotton. 



The physician may give advice on to- 
bacco in a general way, but he will find 
very few patrons who will tolerate his 
presence professionally if he advises them 
to drink less coffee, to smoke fewer cigars, 
to chew less tobacco or to take less whisky. 
They think they know what is good for 
them better than the men who make a 
life-study of the causes of disease, and 
know why and how thev undermine health 
and life.— Ex. 



6 



Original Articles. 



Vol. lxviii 



SOME SUCCESSES AND FAILUKES WITH ELECTRICITY IN 

GYNECOLOGY. 



A. LAPTHORN SMITH, B. A., M. D., M. R. C. S., England. 



My experience with electricity in gyne- 
cology has been limited to : 

1. Positive Galvano-Punctures. 

2. Negative Galvano-Punctures. 

3. Positive Intra-uterine Applications 
of Galvanism. 

4. Vagi no-abdominal Applications of 
Galvanism. 

5. Intra-uterine Bipolar Fine-wire Far- 
ad ism. 

6. Vaginal Bipolar Fine-wire Faradism. 

7. Intra-uterine Coarse-wire Faradism. 

8. Vaginal Bipolar Coarse-wire Fara- 
dism. 

9. Vagino-abdominal Coarse- wire Fara- 
dism. 

Positive Galvano-Punctures. — I have 
had one very marked success with positive 
galvano-puncture in a case of enormous 
uterine polypus, in a patient who was so ex- 
hausted with hemorrhage that no surgeon 
would dare to give her an anaesthetic in 
order to remove the polypus, which was 
the size of a seven months' foetal head, 
and nearly rilled the pelvis. Half a dozen 
positive galvano-punctures were made into 
the tumor as a palliative measure, with 
the result that the hemorrhage and pro- 
fuse watery discharge were stopped, and 
the patient improved so much in health 
that she would not entertain the proposal 
to remove the tumor, apparently suffering 
no inconvenience from it. I followed her 
up for about a year, since which I have 
lost track of her. Although I employed 
currents of 150m., the treatment was 
absolutely devoid of pain. 

On the whole I am opposed to galvano- 
puncture, having lost one case through an 
error of diagnosis and neglect of strict 
antiseptic precautions ; and having, in 
another, caused a good deal of suffering 
without proportionate results. My chief 
objection to it, however, is that it almost 
surely causes adhesion, which in case of 
the necessity ever arising for removal of 
the uterus, would greatly increase the 
difficulties of the operation. A minor, 
but still important objection to punctures 
is that they frighten the patient away from 
continuing the treatment. 

I have to record one complete failure with 
negative galvano-punctures to relieve the 



pain of an impacted non-bleeding fibroid. 
The death above referred to is the only 
fatal or even dangerous accident I have had 
since I first began the use of galvanism. 

With positive intra-uterine applications, 
on the contary, my success has been 
almost invariable. I have employed them 
in rapidly-growing bleeding fibroids, in 
subinvolution, in fungous endometritis, 
and in monorrhagia from other causes, the 
disease having been arrested in about 90 
per cent, of the cases. Success has been 
due to attention to the following points : 

Correct diagnosis ; the introduction of 
a solid or flexible sound the whole depth 
of the uterus ; the employment of a suffi- 
cient current strength to furnish at least 
25 milliamperes to each square centimetre 
of surface of the sound, and the rigorous 
following out of the aseptic and all the 
minor details of the method as laid down 
by Apostoli One of my failures (Miss B.) 
to arrest hemorrhage with positive intra- 
uterine application of galvanism was due 
to the eating into a small uterine sinus 
with the end of the electrode, which, at 
that time, I was not in the habit of taking 
the precaution of insulating with a little 
wax. 

This case would have been a complete 
success had it not been for this accident, 
but owing to the slight hemorrhage lasting 
however, two weeks I was led to class it 
as a failure and the uterus was removed. 
The patient made a good recovery and is 
now enjoying good health. 

It is interesting to note that, although 
she received over 50 strong applications 
with the clay electrode on the abdomen, 
there was not found the slightest sign of 
an adhesion anywhere, except at a small 
spot at the back of the uterus where the 
latter had been rubbing on the brim of the 
pelvis. 

Another failure, Miss S., was due to the 
condition of the appendages which pre- 
vented me from giving adequate doses. 
By the aid of a little anaesthetic occasion- 
ally, I was able to give her 100 applica- 
tions, lasting each from seven to ten min- 
utes and of an average strength of 100 
milliamperes. The tumor was reduced in 
size one-fourth, the haemorrhage was re- 



January 7, 1893. Original Articles. 



7 



dnced fully three-fourth?, and the patient 
regained her color. But her home being 
a thousand miles away, and as she feared 
that the haemorrhage might recur when 
she would not be able to recur for treat- 
ment, she urged me to perform hysterec- 
tomy, which I told her was the only ab- 
solutely certain treatment that would pre- 
vent haemorrhage returning. At the oper- 
ation there was not a sign of an adhesion 
anywhere after 100 applications of galvan- 
ism, some of the doses going as high as 
175 milliamperes. She made a rapid re- 
covery, and is now in excellent health, 
performing her duties as principal of a 
high school where there are 600 girls. So 
far from the treatment with electricity 
making the operation more difficult and 
complicating it with adhesions, I felt con- 
vinced that it had placed her in a much 
better position for undergoing it. I cer- 
tainly should have dreaded undertaking 
the operation while she was in the exsan- 
guinated condition which she presented 
when she first came under my care. If 
she had resided in this city, or anywhere 
where she could have reached me and re- 
ceived further treatment in case of a re- 
turn of the bleeding, she would not have re- 
quired to have undergone the operation 
at all. 

In another case of failure with the posi- 
tive pole (Miss S.,) in the uterus, the pa- 
tient had been sent to me with a diagnosis 
of fibroid, which had been made and con- 
firmed by several leading surgeons. The 
tumor at first diminished in size, and the 
patient's general health was much im- 
proved, but after a time it suddenly began 
to grow again, when I sent her to the 
hospital for operation, at which I was pre- 
sent. The tumor proved to be a sarcoma 
of the ovary into a depression in which 
the uterus was imbedded, rendering it 
difficult to differentiate the one from the 
other by digital examination. 

A brilliant success, however, was a Mrs. 
P. , who had bled so much that, as a last 
resort, a leading gynaecologist in the city 
had packed her with ice. I kept her tam- 
poned with alum tampons for a few days 
until I could improve her enough to 
be carried to my office. The introduction 
of a soft bougie to measure the depth of 
the uterus caused the blood to pour out on 
to the floor of my office before I had time 
to catch it. Her skin was waxy and ab- 
solutely colorless. After twenty or 



twenty- five applications her periods be- 
came perfectly normal, and have remained 
so for several years. I took the trouble 
to hunt her up a few months ago to pre- 
sent her to the medical society, and found 
that she had been in perfect health ever 
since, suffering no inconvenience what- 
ever from the tumor which had been re- 
duced- fully a third. This woman would 
surely have died whether she had been 
operated on or left alone ; in fact, no one 
would have dared to operate on her in the 
almost pulseless condition in which I first 
saw her. 

Another brilliant success wa*s Mrs. S., 
an artist by profession, who had almost 
become a hopeless invalid, but, who after 
only fifteen applications of galvanism was 
restored to almost perfect health, and has 
not lost a day from her work since. The 
tumor was reduced a third in size, and she 
suffered no inconvenience from it what- 
ever. It is now three years since the last 
application, and she has had no relapse. 
Another successful result from the posi- 
tive pole in the uterus was Miss A., 
chambermaid in the Windsor Hotel, who 
was about to abandon her occupation when 
she came under my care, but after fifteen 
applications was able to resume her work, 
and has been well ever since — now two 
years ago 

Mrs. X., wife of a physician in this city, 
used to bleed so severely that she had to 
pass a week out of every month in bed, 
with her feet raised and her head low, and 
even then she would faint repeatedly ; after 
ten applications was so much improved 
that she was no longer obliged to remain 
in bed at all. I subsequently curetted 
the uterus and repaired the lacerated cer- 
vix and perineum, and now she is enjoy- 
ing very fair health. 

Miss A., was sent to me from Scranton, 
Penn. She was an expert stenographer, 
but was unable to keep a situation because 
for ten days in every month she had to re- 
main in bed. If she attempted to remain 
up, large clots would come away, so that 
she would have to stand in the office over 
a newspaper and allow them to fall on it, 
besides which she would saturate a dozen 
napkins a day with the serum. After 100 
applications her periods came down to 
three days, and she is now married. 

Mrs. P., from a distant city had to be 
carried into my office, but was able to 
walk a distance of two miles after having 



8 



Original Articles. 



Vol. lxviii 



received ten applications. She received 
in all 50 applications, the last one three 
years ago, she has remained well ever since. 

One of my most recent successes is Mrs. 
F., of this city, who was affected with 
severe haemorrhages, and who after about 
20 applications was relieved of all her 
symptoms. There has not been any re- 
turn of the haemorrhage since leaving off 
the treatment three months ago. 

Two cases which were sent to me as 
bleeding fibroids were not cured by elec- 
tricity, as they subsequently proved to be, 
one sarcoma, and the other epithelioma of 
the uterus. 

In both, however, the haemorrhage was 
arrested, although one has since died and 
the other will soon die. 

All the cases so far mentioned, with the 
exception of the last two of cancer, were 
cases of bleeding fibroid tumors of the 
uterus and they were all in women under 
40 years of age. They were all treated 
with positive intra-uterine applications. 
In another case of a woman, Mrs. N., who 
had been bleeding steadily for a year, and 
who had also a bad lacerated cervix, there 
seemed no doubt about the cancerous 
nature of the disease. Haemorrhage was 
permanently arrested by only half a dozen 
applications of the positive pole. My 
success in this case led me to entertain 
the hope that we had at hand a cure 
for uterine cancer, but in another case far 
advanced the treatment proved an utter 
failure. If it is to be of any use the cases 
must be seen early. 

Besides these 15 cases I have treated 
about 45 cases with the positive intra- 
uterine pole, for other conditions, princi- 
pally for fungous endometritis, endome- 
tritis with haemorrhage at the periods, but 
also in cases of subinvolution. Of these 
45 cases I can only recollect two failures 
to arrest the haemorrhage. In every case the 
depth of the uterus was diminished. There 
has been no failure to produce this result. 
In one case the effect was especially gratify- 
ing. An old lady with her womb lacerated, 
large and heavy, hanging between her legs, 
to whom I administered about half a dozen 
positive applications followed by coarse 
wire faradism. The womb became re- 
duced to its normal weight so that a little 
toning up of the supports rendered them 
able to keep the organ within her body, 
where it remained till her death, two 
years later, from apoplexy. 



The following cases were treated with 
negative intra-uterine galvanism, and gave 
me some of my most brilliant results. 

Miss W. , who had suffered agony for 
several years from pressure on the urethra 
and rectum, and was obliged in conse- 
quence to abandon her occupation as cook 
in a gentlemen's family, was completely 
cured four years ago by about 20 applica- 
tions, so that she was able to start and 
carry on sucessfully a large boarding house 
for which she now does both the cooking 
and the catering. The last time I exam- 
ined her the tumor could not be felt. 

Mrs. D., from a town near here, had 
suffered for 8 years from pressure symp- 
toms, but not from bleeding, from a large 
intestinal fibroid. Her health had been 
completely broken down by the large 
quantities of morphine which her suffer- 
ing necessitated. One hundred applica- 
tions cured her, so that two years after- 
wards her physicians wrote me that the 
tumor had entirely disappeared. Al- 
though it is now over four 3^ears since her 
treatment, menstruation is regular and 
painless, and she continues in excellent 
health. 

Miss McP.,- suffered so much from 
pressure symptoms that she was obliged 
to give up her situation as cook. Her 
tumor was growing rapidly. After about 
20 applications the growth was arrested, 
and she felt so well that she entered the 
writer's service, where she has ever since, 
now five years, performed her duties with- 
out interruption. 

Mrs. D., from Holyoke, had a large 
submucous fibroid which was growing 
rapidly. After the first application there 
was no increase, while after the tenth there 
was so much diminution in the size of her 
waist that she decided that she was cured, 
and started for home. She was taken 
with severe expulsive pains on the train, 
and soon after reaching home she gave 
birth to a broken down fibroid about the 
size of a seven months child's head, since 
which she has enjoyed good health. 

In half a dozen other cases of fibroid 
the pains and pressure symptoms were 
fairly well relieved by negative applica- 
tions. 

In the treatment of dysmenorrhea 1 have 
had some very gratifying results, so that 
I can say that I know of no treatment ex- 
cept removal of the appendages which can 
offer such good prospects of relief. Since 



January 7, 1893. 



Original Articles 



9 



reporting nine cases of dysmenorrhea 
cured by negative galvanism, I have added 
half a dozen more to the list, while only 
one has utterly failed to be relieved, and 
one relapsed until she received two more 
applications^ since which she has remained 
well. 

With sacro-abdominal application of 
galvanism I have not had any marked 
success, although I have only given it a 
limited trial. 

With vagino-abdominal applications, 
I have seen the tender, enlarged 
and prolapsed ovaries become lighter, 
painless and to disappear from Doug- 
las' cul de sac. I have also on three 
occasions seen the uterus, which was pre- 
viously bound down and retroverted, 
become movable. While I can hardly 
believe that organized bands of adhesions 
can be dissolved, or, in the words of the 
electro-therapeutical poet, ' ' Melt away 
like snow before the summer sun, 1 ' I can 
believe that such a powerful alterative may 
so improve the circulation in the lymph- 
atics that soft or liquid exudations may be 
reabsorbed. 

With bipolar fine-wire faradism, I have 
treated at least 50 cases, principally of 
inter- menstrual pain, due to neuralgia of 
the uterus and ovaries, and of varicocele 
of the pampinniform plexus. I have 
sometimes used it in some of the above 
mentioned cases of fibroid in order to 
establish tolerance for the galvanic current. 
For any kind of pain in the pelvis, in 
which no organic disease of the uterus or ap- 
pendages could be felt by careful bimanual 
examination, I have found bipolar faradism 
invaluable. 

Where it has failed to relieve, subse- 
quent operation has revealed undiagnosed 
pus in the pelvis, foi which, of course, 
there is only one treatment, and that is 
evacuation. I have sometimes used it in 
the uterus, but most often in the vagina, 
which seems to be much safer and almost 
as effectual. 

With coarse-wire faradism I have also 
had very satisfactory results in cases of 
retroflexion due to atony of the uterus 
and ah-o in cases of prolapsus. In one 
case of procidentia of a very advanced 
type it failed to keep the uterus up ; but 
in at least a dozen other cases of more 
moderate degree in which the uterus was 
not much enlarged, a few applications of 
coarse wire faradism toned up the relaxed 



vagina and perineal muscles, especially 
the levator, and that the women have 
declared that they were greatly relieved, 
and some of them have even returned each 
succeeding summer during the hot weather 
to have their pelvic contents toned up. 

The subinvoluted uterus, like the uterus 
at the end of pregnancy, responds very 
readily to the faradic stimulus, and any 
one who has employed coarse-wire bipolar 
faradism in the vagina cannot have failed 
to notice how the electrode is grasped by 
the sphincter of the vulva and drawn up 
by the levator ani. 

Vagino- abdominal coarse-tvire faradism 
I have used several times with the view of 
shortening the round ligaments, as it has 
been demonstrated that the freshly re- 
moved round muscle will, when stimulated 
by the faradic current, lift a weight of a 
pound and a half off the table. But the 
result was too slow in coming, so I was 
tempted to perform Alexander's operation 
instead. 

As this paper is entitled some " suc- 
cesses and failures w T ith electricity in 
gynecology," I have not given a very 
detailed account of every case. It is 
rather a general stock-taking after nearly 
five years experience with it. 

As far as I know the harm I have done 
with it has been limited to one death and 
two miscarriages all due to mistakes in 
diagnosis. I believe that I have saved at 
least 20 women from operation and three 
or four from death, while I am absolutely 
positive, certain electrophobists to the 
contrary notwithstanding, that in those 
whom I treated with electricity, but whom 
I did not save from operation, the opera- 
tion was in no way rendered more difficult 
thereby, but in all probability their 
chances were improved, all of them having 
made easy recoveries. 

I think it is unjust and unfair for my 
friend, Dr. Joseph Price, and others to 
lay all the blame of adhesion on electric- 
ity when they know as well as I do that 
these complications are met with in cases 
which have never been touched with elec- 
tricity, while on the contrary they know 
that cases which have been treated for a 
year with electricity were found at the 
operation to be absolutely free from ad- 
hesions. 



A hot infusion of capsicum is recom- 
mended for hiccough. 



10 



Clinical Lectures. 



Vol. lxviii 



CLINICAL LECTURES. 

CARCINOMA UTERI.* 

E. E. MONTGOMERY, M. D., Philadelphia. j~ 



Ladies and Gentlemen: — I show you a 
patient thirty-five years of age, native of 
Russia, who, unable to speak English, af- 
fords us a very imperfect history. She 
had none of the diseases of childhood, and 
enjoyed excellent health until after the 
birth of her last child ; married at eighteen, 
has had eight children; five died in in- 
fancy, three living and healthy. All her 
labors were normal and she has had no 
miscarriages. 

After the birth of the last child, 
menstrual periods occurred at intervals of 
two weeks; flow was profuse, no pelvic 
pain. Nine weeks ago she was so weak as 
to be unable to go about. She at present 
complains of intense pain along the thighs 
and of headache. The other symptoms are 
gastric ; burning sensations in the stomach 
and along the oesophagus; flatulence, 
vomiting, bowels obstinately constipated, 
urine negative. She has a profuse watery 
discharge from the vagina, greenish in 
color, andwith an exceedingly offensive odor. 

Now the history of this patient, 
her age — thirty-five years — married at 
eighteen years, suffering for three years 
from profuse menorrhagia, and profuse 
hemorrhage occurring as often as every 
two weeks, severe pain and profuse offen- 
sive discharge. These symptoms would 
at once cause you to suspect some serious 
diseases of the genital tract. In examin- 
ing the patient we find the vagina filled 
up by a mass, projecting into it from the 
right side, and anteriorly a large mass 
which on its lateral surface is smooth in 
outline; as we pass toward the central 
part it is quite friable. This mass is 
found to fill up the pelvis, pressing upon 
the surrounding organs and is so friable if 
we make much pressure against it, it 
would break down and hemorrhage would 
result. We have here a degeneration 
which is without question malignant. 

Diseases of this kind are much more 
likely to be found in women of an older age 
It occurs more particularly near the climac- 
teric, or immediately following it. It is a 
condition which is found with greater 

* Delivered at the Phila Hospital, Novemher5th, 1892. 

t Professor of Gynaecology, Jefferson Medical College; 
Obstetrician to Philadelphia Hospital; Gynselogist to 
St. Joseph's Hospital. 



frequency in women, who like this one,, 
have borne a number of children. While 
it occurs with greater frequency between 
the ages of forty or fifty, its presence 
should not be overlooked when symptoms 
such as these present themselves in young 
women, as I have seen a patient in this 
house dying with cancer who was but 
twenty years old. As we have already 
said, it occurs more frequently in women 
who have borne a number of children 
The cervix is the usual seat of the dis- 
ease. We can readily understand why the 
woman who has borne a number of chil- 
dren and has consequently suffered lesions 
daring parturition, which have been but 
partially repaired by the processes of Na- 
ture, should be more likely to suffer from 
such degenerations. Tissue of low vital- 
ity, subject as it is to frequent irritation, 
is likely to take on malignant change. 

Because the disease, however, occurs so 
frequently in women who have given birth 
to children, and is in the majority of cases 
found in the cervix, it should not be for- 
gotten that it may occur in women who 
have never been pregnant, and is also 
found in the body of the uterus. I had a 
patient in this house, about fifty years of 
age, suffering from hemorrhage, who had 
an unruptured hymen and yet the entire 
cervix was destroyed by an epithelioma. 
In about two per cent, of the cases the 
disease is found in the body of the uterus. 
The disease begins in the glandular tissue 
of the organ, and subsequently invades by 
processes of infiltration the subjacent mus- 
cular structure, until the entire organ may 
be involved. 

The symptoms of the disease will 
depend much upon its form. Thus, 
in the epithelioma we may have ex- 
tensive cell proliferation, formation of 
large masses, oftentimes cauliflower in 
character, which may fill up the entire 
vagina, are exceedingly friable, breaking 
down under the touch, and bleed from the 
slightest irritation. In these cases pain is 
not usually a marked symptom. Some 
patients indeed, go through the entire 
progress of the disease without suffering 
from pain. In the variety known as scir- 
rhus, there is a firm infiltration of the 



January 7, 1893. 



Clinical Lectures. 



11 



walls of the uterus, giving rise to a hard, 
dense mass. In these cases the pain is in- 
tense, due without question to the pressure 
upon the involved nerves; one of the earl- 
iest symptoms is hemorrhage. This may 
be an increase of menstrual flow, a slight 
bloody discharge in the intervals, or a re- 
turn of bloody flow after the establishment 
of the menopause. The occurrence of 
haemorrhage should always be considered 
a suspicious symptom, indicating the 
necessity of careful examination of the 
genital tract to determine its cause. While 
hemorrhage at the climacteric, or follow- 
ing it, is usually regarded as a suspicious 
symptom of malignant disease, it does not 
always necessarily follow that such disease 
is present. I remember, some years ago 
being called in consultation to see a 
patient forty-five years of age, who had 
had two children, was suffering from ir- 
regular menstruation with severe pain. 
Examination disclosed the cervix appar- 
ently normal ; the mere introduction, how- 
ever, of the sound into the uterus was fol- 
lawed by profuse flow. Her age, associa- 
tion of pain, and hemorrhage, led me to 
believe that she was suffering from malig- 
nant disease of the mucous membrane of 
the body of the organ. The removal of 
the uterus was advised and was subse- 
quently done by the vaginal method. 
Upon opening the organ I was much dis- 
comforted to find that the hemorrhage had 
resulted from a submucous fibroid the 
size of a hickory nut in the wall of the 
fundus. For this reason I say that such 
patients should be subjected to a very 
careful examination to determine certainty 
that the disease is not malignant. Hem- 
orrhage may also result from a papillary 
growth of the uterine mucous membrane, 
which, while it is not malignant, may 
possibly be a forerunner. These patients 
usually, however, are cured by careful 
curetting of the cavity. 

Another constant or early symptom of 
malignant disease is offensive discharge. 
This, not unfrequently, is thin and watery, 
giving an odor of decaying flesh. It is 
very noticeable to the patient and those 
who may come in close proximity to her. 
The discharge arises as a result of a break- 
ing down of the infiltration, and taken 
together with haemorrhage and with pain, 
is a very reliable symptom. It should not 
be forgotten, however, that the patient 
may have an abortion and retained pla- 
centa, or portions of the decidua which 



may disintegrate and undergo putrid de- 
composition, causing an offensive odor. 
Then, too, fibroids of the uterus may have 
lost their vitality, become sensibly sepa- 
rated from the wall of the organ to such a 
degree as to slough, giving rise to thin, 
watery discharge, to an odor of putrid 
flesh, so that even this symptom requires 
careful physical examination before it can 
be considered as a pathognomonic sign. 

In enumerating the symptoms, then, of 
cancer, we have: haemorrhage, rarely absent; 
offensive discharge, usually present; pam 
of a radiating character, sharp, lacinat- 
ing, sometimes felt in the sacral and 
lumbar regions, extending down the 
thighs, not necessarily a constant symp- 
tom. 

After the disease has continued for a 
length of time, as a result of haemor- 
rhage, or the loss of rest, and pain, with 
the drain from the discharge and the ab- 
sorption of septic material, the patient be- 
comes anaemic, pale, emaciated, presents 
a sallow,, cachectic appearance, the result 
of septic absorption. This cachectic ap- 
pearance, of course, may be associated 
with other conditions, as loss of blood, 
from presence of fibroid, severe haemor- 
rhage following an abortion, with reten- 
tion of decomposed clots or placenta and 
the absorption resulting from it. As the 
disease pursues an uninterrupted course, 
we find it extending from the structures 
first involved to those in the immediate 
proximity, involving one or the other lip 
of the uterus, extending into the vagina, 
infiltrating its walls and subsequently in 
processes of ulceration, opening either in- 
to the bladder or rectum, or in some cases 
into both, producing thus a cloaca into 
which urine, feces, and discharges inix, 
giving rise to the most offensive odor that 
could be possibly imagined. 

As the disease progresses it is rare to 
find the peritoneal cavity opened by it, for 
the reason that Nature interposes a barrier 
of lymph, the parts become thickened and 
the cavity thus shut off. 

In a patient with the disease so ex- 
tensive as the one we have before 
us, we will ask, " What shall be done?" 
So far as any attempt at radical cure, 
nothing. The disease has extended 
beyond the uterus into the pelvic struct- 
ures to such a degree that no operation 
could accomplish its entire removal. Any 
operation consequently is worse than use- 
less. It is not right to subject the pa- 



12 



C linical Lectures. 



Vol. Ixviii 



tient to a dangerous operation which af- 
fords no hope of radical cure. In this pa- 
tient, the use of the curette, cutting away 
the diseased tissue, will decrease for a 
time the unpleasant odor, might possibly 
arrest haemorrhage, but upon the denuded 
surface thus formed, the cancer cells would 
implant themselves, infiltration would be 
more rapid and the death of the patient 
occur sooner than if we did nothing. The 
use of the cautery or caustics, after curett- 
ing in some cases, is attended with very 
beneficial result, patients recovering for 
a time, appearing in fairly good health 
until the disease again has extensively de- 
veloped. 

There are other cases, however, 
which may appear fully as promising at 
the time of operation, in which the method 
of treatment seems, if anything, to hasten 
the progress of the disease. Wh ere the dis- 
ease involves the anterior lip, and extends 
from it to the vaginal wall, we not unfre- 
quently find the infiltration pressing upon 
the orifices of ureters, giving rL«e to diffi- 
culty in passage of urine. Its accumula- 
tion consequently in the kidneys causes 
the development of an uraemic condition 
which hastens the fatal termination, and 
during which, as a result of its retention 
in the blood, the patient is much less cog- 
nizant of pain. In this respect it is a 
rather satisfactory form of progress. 

In this patient nothing remains but to 
make her as comfortable as can possibly be 
done during the remainder of her life. In 
order to do this we will direct that ano- 
dynes shall be given, to give her rest at night 
and ease her pain. In giving anodynes, 
it is well enough not to begin with opium 
or morphine, but rather to save these 
agents for a later period, giving in their 
place a palliative, as hyoscyamus, chloral, 
and the less active anodynes, not to save 
the patient from the formation of the 
opium habit, but rather to economize 
the effects of that drug, so that when she 
reaches a period of stage of the disease 
in which it is needed, we may have 
it still to resort to. 

Locally, patients should be given 
vaginal enemas, bichloride or acid 
sublimate solutions, solutions of sul- 
phurous acid or carbolic acid, or what 
is more effective probably than any, a solu- 
tion of thymol, the latter agent for the 
purpose of removing the offensive odor. 
The patient should be kept in a room that 



is well ventilated, and in the late stages of 
the disease, where the odor is marked, she 
should wear at night a skirt of oil cloth or 
rubber pinned about the waist in order to 
prevent her being offended by the exhala- 
tions rising. 

We have already spoken of the 
method of curetting the uterus and the 
subsequent application of caustic. This 
treatment was suggested by Sims but later 
developed by Van deWarker. It consists 
in cutting away as much of the diseased 
tissue as possible, drying the surface and 
controlling haemorrhage by packing the 
vagina with cotton saturated with Mon- 
sell's solution. At the end of twenty-four 
hours this packing is removed, the sur- 
face cleansed and then packed with cotton 
saturated with a solution of chloride of zinc, 
varying in strength according to the ex- 
tent of the disease. When there is quite 
a thick wall, affording opportunity for ex- 
tensive slough, without destroying immedi- 
ate structures, a saturated solution may be 
used. Where the intervening layers are 
thin, it may be used in the strength of six 
drachms to the ounce. In using the caustic 
it is very important to carefully protect the 
healthy tissues and walls of the vagina by 
covering it with an ointment consisting of 
two drachms of bicarbonate of soda with 
an ounce of cosmoline. The cotton tam- 
pons wet with a solution should be care- 
fully squeezed out so as not to have any 
superfluous fluid to run over the pelvic 
tissue. A tampon of cotton should be 
applied below it and then one wet with a 
saturated solution of bicarbonate of soda. 
Bicarbonate of soda decomposes chloride 
of zinc and thus destroys its caustic action. 
Even with these precautions, however, un- 
less very great care is taken, the superflu- 
ous fluid will run over the vagina, giving 
rise to considerable cauterization of the 
outlet of the canal. A case occurred in 
the practice of a gentleman of this city, 
in which the application of this caustic 
resulted in a slough of vaginal walls, caus- 
ing an opening into the bladder and rec- 
tum and with an extensive sloughing of 
the diseased tissue of the uterus. The 
patient recovered from the operation with 
a recto-and-vesico-vaginal fistula. The 
tissues contracted, making the canal so 
small that it was impossible to dilate it 
sufficiently to repair and close these fis- 
tula. The condition of the patient con- 
sequently was a deplorable one; one in 



January ?. Ih93. 



Clinical Led a res. 



13 



which death would have been preferable* 

In the patient we have before us, I do 
not consider that this plan of treatment 
would be applicable, for the renson that 
the intervening wall between the bladder 
and vagina would be opened, and possibly 
that also of the rectum. The tampon 
should be removed at the end of forty- 
eight hours or earlier, if there are indica- 
tions of developing sepsis; the patient 
kept in bed and douches used twice a day 
subsequently until the slough has com- 
pletely separated and the surface granu- 
lated. Throughout the tenth day it is 
quite important to have the patient 
watched carefully for fear that haemor- 
rhage may result through opening of 
large vessels from the slough. If there is 
a tendency to bleeding, the nurse should 
be directed to use a vinegar douche and 
this followed, if necessary, by a douche 
containing the per sulphate of iron. If 
we are called to see a patient before the 
disease has extended outside the uterus, 
or while it is still confined within the 
organ, whether involving the cervix or the 
body, the operation, above all others, to 
be considered is the extirpation of the 
uterus. To determine the condition, 
however, and. whether such an operation 
is suitable, we should not be content with 
vaginal examination alone, but should 
always examine by the rectum. By so 
doing we are enabled to ascertain the ex- 
tension of the disease to the posterior 
surface of the broad ligament, the infil- 
tration that would thus result, nodules 
that may be present and the movability of 
the uterus. 

It is true that operations are done 
for amputation of the cervix where 
malignant disease is confined to one or the 
other lips of the uterus; but when we con- 
sider that the disease extends to a greater 
degree along the mucous membrane, we 
can readily understand that there may be 
cells situated above the point at which 
amputation takes place, which will be the 
nidus for subsequent development of the 
disease. 

It would seem that the removal of 
the uterus is just as certainly indicated 
in cancer of any portion of it, as would be 
the removal of the entire breast wh pre one 
lobe of this organ is the seat of malignant 
disease. 

With the importance of rectal ex- 



amination in such cases. I was very thor- 
oughly impressed some years ago, upon 
examining a patient whom I had already 
advised to undergo vaginal hysterectomy. 
At a second visit she informed me she hud 
considerable irritation of the rectum. I 
made an examination and found extensive 
ulceration and infiltration of its wall with- 
out any direct indication or connection 
with disease of the uterus. The presence 
of this condition in the rectum, precluded, 
of course, any operation. If I had ne- 
glected this, the patient might have been 
subjected to a hysterectomy, and the rec- 
tal trouble overlooked. The extirpation 
of the uterus by vagina is not necessarily 
a very dangerous one. In the hands of 
such men as Martin and Leopold, the mor- 
tality has been reduced to but little more 
than five per cent. The operation is one, 
in favorable cases, that can be very readily 
and speedily performed. It consists in 
making au incision behind the cervix, 
which is firmly held by a Volsellum, the 
tissue pushed off in front, and behind, 
until the peritoneum is reached. The 
vagina is opened posteriorly and a sponge 
attached to it to hold up the intestines 
and prevent the peritoneal cavity from 
being soiled with blood. The opening is 
then made through the peritoneum ante- 
riorly, leaving the organ attached by its 
broad ligaments. Upon the ringer, one 
blade of the modified Greig Smith clamp 
is passed behind the broad ligament. The 
other blade is parsed in front. The.-e are 
locked and the external end screwed down, 
until the broad ligament is thoroughly 
compressed. This ligament is then cut 
off close to the clamp, the uterus dragged 
down, the clamp applied to the opposite 
side and it cut off as well. The clamps 
are now held one on either side of the 
vagina and the sponge withdrawn from 
the cavity. The vagina may be irrigated, 
washing out blood, and after drying it, an 
iodoform gauze tampon is introduced, 
carrying the gauze carefully upward on 
either side over the end of the clamp, in 
this way protecting the intestines from 
contact with it. The end of both clamps 
is thus covered, the vagina pretty comfort- 
ably packed with gauze and the patient 
placed in bed. They usually suffer very 
little inconvenience, and it is but rare that 
an anodvne is found necessary. The 
clamps are removed at the end of twenty- 
four hours; the gauze packing in four or 



Communications. 



Vol. lxviii 



five days. Some plain gauze or antiseptic 
cotton is kept over the vulvar outlet to 
receive the discharges. Usually the dis- 
charge is pretty free for the first twenty- 
four or thirty-six hours. In performing 



this operation it is very important not to 
injure the bladder when we cut around 
the uterus, and particularly ' important to 
avoid injury of the ureters, either with the 
knife or the clarnp. 



COMMUNICATIONS. 



THE TREATMENT OF INCISIONS IN THE - ABDOMINAL WALLS, AND 

VENTRAL HERNIA. 



G. D. LADD, M. D., Milwaukee, Wis.* 



In closing a wound in the abdominal 
walis three important points should be 
considered, viz. : the prevention, if pos- 
sible, of adhesion of adjacent abdominal 
viscera to the abdominal parietes ; the pre- 
vention of ventral hernia; the prevention 
of stitch abscess and wound infection. 

The frequency with which adhesion to 
the abdominal wound follows laparotomy 
cannot be accurately determined, but from 
our knowledge of the behavior of the 
peritoneum, and from autopsies in cases 
which have previously recovered from 
such operation, we can reasonably con- 
clude that it is a very frequent or perhaps 
usual occurence. That such adhesions are 
usually productive of no harm or discom- 
fort is attested by the large percentage of 
cases in which the clinical result shows 
freedom from all pain or discomfort at 
this point. It may even be claimed that 
such adhesions are an advantage in render- 
ing more secure union of the wound. A 
careful consideration of the condition 
which obtains where ventral hernia exists 
shows, however, that such is not the case, 
for they exert little or no influence in pre- 
venting the protrusion and a proper union 
of the wound is of itself always sufficient 
toprevent the occurrence. 

Adhesion of one or more loops of the 
small intestine to the abdominal wall is, 
however, sometimes productive of great 
discomfort and pain, and, as it is our aim 
to leave the contents of this cavity in as 
nearly the normal condition as possible, 
the prevention of this complication be- 
comes quite an important desidera- 
tum. 

As any rough handling or injury to the 
peritoneum near the incision favors aa- 

*Surgeoii to St. Mary's Hospital. 



hesion, it is important to avoid this in so 
far as possible. For this reason the 
peritoneum should be divided by a careful 
incision with either the scissors or a sharp 
knife. In using retractors, or in sponging, 
care should be taken to avoid all unneces- 
sary rubbing or friction upon this tissue. 
Morris has demonstrated, in experiments 
upon animals, that Aristol dusted and 
rubbed upon any injured portion of 
the peritoneal surface is innocuous and 
will prevent adhesion. While its use will 
not become general in closing these wounds 
it may be at times of very great service. 

Ventral Hernia. — Ventral hernia, al- 
though a remote risk, has followed in- 
cisions in the abdominal walls and that 
sometimes in the hands of very skillful 
surgeons, and its consideration is a matter 
of importance whenever we close these 
wounds. 

Various modes of applying the sutures 
have been in vogue at different times and 
are in favor with different operators. In 
the early days, and by some at the present 
time, all of the abdominal wall was in- 
cluded in each suture, and the results 
were good. Later and by others the 
sutures were made to include the skin, 
fascia and peritoneum. More lately the 
custom has been to include one or more 
layers in a. single set of sutures, the perito- 
neum, muscles and fascia, and skin being 
sutured separately. 

Whatever plan is followed it is of first 
importance that the fascia be securely 
united throughout its entire extent. Fail- 
ure to properly secure this structure it is 
that allows a ventral hernia to occur. A 
good plan to follow is to include the peri- 
toneum, singly, in a continuous suture, 
next including the muscle and fascia in 



January 7, 1893. 



Co n i m i mica t ions. 



15 



a set of interrupted sutures, and lastly 
suture the skin separately. 

When ventral hernia exists as a result 
of an incision, through the abdominal walls 
it is because there has been failure to 
secure complete union of the fascia. The 
comparatively rare occurrence of this com- 
plication is due to the fact that a suture 
passed through the muscle usually in- 
cludes the fascia, or it is included in and 
held by cicatricial tissue. The treatment 
then, for ventral hernia consists in dis- 
secting out the edges of the fascia, in one 
or more layers according to its anatomical 
conformation at the point of incision, and 
approximating them firmly by frequent 
interrupted sutures, as many as three to 
the inch. The edges of the fascia will be 
found to have retracted and curled up, 
often being obscured by cicatricial tissue. 
Frequently a large pocket will have been 
formed by a gradual separation of two of 
the layers of muscle, and the surfaces, be- 
ing constantly subjected to slight friction 
become infiltrated and smoothed until 
a fair substitute for a serous surface is 
established, In proportion as these sur- 
faces have become old and thickened does 
it become difficult to occlude the cavity. 
It may be necessary to freshen the sur- 
faces where they will be included in the 
sutures which close the abdominal wound, 
thus securing immediate union at this 
edge. A counter- opening, leading to the 
surface, at the outer edge of the pocket, 
will allow of its being packed and sub- 
jected to such subsequent treatment as 
may be necessary. 

Prevention of stitch-abscess and 
■wound-infection. — We here touch upon 
a very broad and interesting subject, but 
shall not enter into it except to consider a 
few points lately demonstrated as neces- 
sary in order to secure uniformly good re- 
sults. For the sterilization of instruments 
and silk a high degree of heat is the one 
means upon which we can rely. The next 
factor to be eliminated, taking the steps of 
au operation in order, is infection from 
the skin. All are familiar with the 
methods employed for this purpose and 
probably, also, with the fact that no matter 
how carefully and thoroughly they are 
resorted to there is frequentiy a failure to 
prevent slight suppuration around the 
stitch, even when the needle and material 
used for sutures are aseptic beyond sus- 
picion. 



The ordinary cleansing and chemical 
disinfection, if thoroughly carried out, 
removes or destroys the many bacteria 
that are upon the surface of the skin. 

Welch, however, describes a coccus of- 
ten seen by others and identified as the 
staphylococcus pyogenes albus, but which 
he individualizes by naming it the staphy- 
lococcus epidermis albus, found in the 
deeper layers of the skin, and which is not 
reached or destroyed by any known means 
of cutaneous disinfection save the appli- 
cation of heat. 

To obtain cultures of this coccus, silk, 
proven by previous test to be aseptic, is 
drawn through skin, which has also been 
disinfected so that scrapings from its sur- 
face give negative results, and placed in a 
culture medium. That this coccus is pro- 
ductive of only slight and limited suppu- 
ration about the stitch is proven by the 
very limited amount of disturbance which 
exists where it alone is found. It, how- 
ever, interferes with the integrity of a 
wound and may thus allow of more serious 
disturbance. 

In cleansing the hands of the operator 
and assistants, the prolonged soaking and 
rubbing of the cuticle in water as hot as 
can be borne, thus softening and remov- 
ing the outer layers of epithelium and at 
the same time applying heat, will greatly 
aid in rendering the surface germ-free. 
The method of chemical disinfection which 
seems to be the most thorough is, after 
the above cleansing, to soak the hands in 
a warm saturated solution of permanganate 
of potash, rubbing them thoroughly ; plac- 
ing them in a warm saturated solution of 
oxalic acid until completely decolorized; 
immersing them in a strong solution of 
corrosive sublimate thereafter. 

As living tissues are known to resist the 
development of bacteria, or to a certain 
extent dispose of them, it becomes very 
important that the integrity of the tissues 
be not interfered with. For this reason, 
in making an incision the tissues should 
be nicely divided with a sharp knife, and 
tearing or stretching avoided. The use 
of chemical disinfectants within a wound 
has been found to cause a superficial nec- 
rosis which favors, or forms a medium for 
the multiplication of pyogenic bacteria and 
should be avoided. In tying sutures care 
should be taken to avoid constricting the 
tissues so as to interfere with their nutri- 
tion. 



16 



Communications 



Vol. lxviii 



In choosing a material for sutures silk 
seems to answer the requirements better 
than any other substance. It can be quickly 
and easily sterilized by heat at the time of 
operation, undergoing thereby no change 
in size, strength, or flexibility. 

Klemm, by repeated experiments, has 
demonstrated that catgut can be rendered 
germ-free and kept so, but that, buried in 
a wound, this softening non-resistant sub- 
stance is a favorable medium for the 
growth of germs. In silk, buried in like 



manner, few or no germs were found. 

The peritoneum then should be closed 
with a continuous suture of fine silk. 
Tne fa-cia and muscle by an interrupted 
suture of medium sized silk. It has been 
recommended that the use of skin sutures 
be abandoned, as excellent coaptation can 
be obtained by subcutaneous sutures. If 
skin sutures are used they should be re- 
moved early. The usual dry aseptic 
dressing retained by plasters or a bandage 
is all that is required. 



THE ASEPTIC AND ANTI-SEPTIC CAEE OF THE LYING-IN WOMAN 

AND NEW-BORN CHILD.* 



H. Gr. NORTON, M. D., Trenton, N. J. 



Inasmuch as it is our duty as physicians 
to use every known means to limit ma- 
ternal and infant mortality during the 
puerperal period, I shall briefly give my 
views of the proper conduct of a case of 
labor and the early care of the child, hop- 
ing to bring out valuable discussion on 
this important subject. 

1st. The physician himself should be 
clean and wear clean clothing. I like to re- 
move the usual coat and put on one of 
clean white linen. The hands, as a ready 
means of introducing infection, need 
special care. It is sufficient, I think, to 
pare and clean the nails carefully, then 
wash thoroughly with hot water and soap, 
using the nail brush vigorously, followed 
by the free use of a germicide solution and 
the nail brush. 

A very thorough procedure would be 
after the method of Prof. Keen, viz. : 
wash the hands with soap and hot water, 
using the nail brush, then wash in alcohol, 
then in a permanganate of potash solution, 
which is to be washed off in an oxalic acid 
solution. To complete all dip the hands 
in a bichloride solution. 

2nd. Not less important than cleanliness 
on the part of the physician is a clean nurse. 
The nurse should wear cotton dresses, not 
woolen ; her hands should be as scrupu- 
lously clean as her whole attire. Often, I 
think, cases of puerperal fever are due to 
an unclean and untidy nurse rather than 
to any want of carefulness on the part of 
the physician. 

Many people expect a nurse to aid in the 

*Read before the Mercer Co. Med. Soc, Nov., '92. 



work of the house and of the family, in ad- 
dition to her care of the mother and child. 
This we should discourage and explain 
our reasons therefor to our patients. 

As to the woman about to be confined, 
she should be regarded as a surgical case ; 
be made absolutely clean and prepared 
several days before the expected confine- 
ment by soap and water cleansing of the 
vulva and a daily immersion bath. Upon 
the first manifestion of pains give an 
enema to empty the lower bowel. This 
removal of feces from the rectum facili- 
tates the birth of the child, makes it 
pleasanter for the physician, and removes 
a great source of danger of infection from 
mother and child; afterward the genitalia 
must be rendered aseptic by the use of 
antiseptic solutions. 

3d. Give a copious antiseptic vaginal 
douche and cover the vulva with an antisep- 
tic pad secured in place, then see your 
patient placed in a clean bed. Here, if it 
were possible, it would be well to have a cot 
purposely for confinement, from which the 
woman could be removed and placed in her 
bed at the termination of the labor. In any 
event we must see that the bed is clean and 
fresh and allow no sheets upon it that have 
not been laundried since used. Rubber ob- 
stetric pads are a great convenience for use 
during delivery and prevent soiling the bed . 
Keep the vulva covered with a clean bi- 
chloride napkin during labor and after. 

When the patient has been properly ar- 
ranged the physician should make a pre- 
liminary vaginal examination after thor- 
oughly disinfecting his hands. As few ex- 



January 7, 1893. 



Society Reports. 



17 



animations as possible should be made. 
We should endeavor to be guided by ex- 
ternal abdominal examinations as far as 
can be, and even by sight, during the pro- 
gress of the head, rather than make frequent 
digital examinations. 

After delivery the emptied womb should 
be regarded as an open wound and treated 
as such. Examine the perineum at once, 
and if lacerated repair it ; keep the vulva 
covered with an antiseptic napkin duriug 
the continuance of the flow. Don't allow 
the use of any old pieces of muslin that 
happen to be at hand for this purpose. 

YVe naturally next turn our attention to 
the child, and after announcing its sex and 
assuring the mother that it is not marked, 
we proceed to take such care of it as will 
prevent septicaemia from the cord or puru- 
lent ophthalmia. Often, I fear, when a 
child dies within a few days after birth, 
we complacently give marasmus as the 
cause, deceiving the parents and still worse 
ourselves, when it was often, doubtless, 
due to septicaemia, due to improper care of 
the cord. Where an infant has fever it is 
probably septic. Don't tie the cord with 
any chance piece of string but with a 
proper ligature which you have with you. 
We should endeavor to have a dry, rather 
than a moist gangrene of the cord, to at- 
tain which we would not of course allow 
the nurse to wrap it in a greased rag, but 



envelop it carefully in an antiseptic dress- 
ing of either borated or salycilated cotton, 
or gauze, and dress it daily; over all 
should be a soft flannel binder. 

We should endeavor to prevent ophthal- 
mia neonatorum by attention to the child 
as soon as born. Its eyes should be wiped 
out at once and one drop of a two per cent, 
solution of nitrate of silver dropped in 
each eye, after the method of Crede. 
Where the vagina is carefully syringed be- 
fore labor infection is less likely to occur. 

Not less important is it to know that our 
forceps and other instruments are antisep- 
tic before using them and there is usually 
time to make them so. 1 would boil all 
instruments likely to be used for five min- 
utes in a clean covered pot, containing a 
tablespoonful of washing soda to the quart. 
The use of the soda prevents instruments 
from rusting, a good thing of itself. 

Our obstetric satchel should contain a 
rubber perineal operating cushion, obstet- 
ric forceps, needles and holder, syringe, 
chloroform, ligatures, antiseptic gauze, 
catheter, boracic acid, tincture of iodine, 
and creolin. To properly conduct a case 
of labor to a successful issue requires the 
highest skill, tact and knowledge, besides 
it is very exhausting to the attending phy- 
sician. In view of these facts we should 
charge a fee commensurate with good ser- 
vice and make the service worthy of the fee. 



SOCIETY REPORTS. 

THE MILWAUKEE MEDICAL SOCIETY. 



Meeting of November 22nd, 1892. 



Dr. G-. D. Ladd, Milwaukee, read a 
paper entitled "The Treatment of Inci- 
sions in the Abdominal Walls and Ven- 
tral Hernia. "(14) 

DISCUSSION. 

Dr. H. M. Browk: I must take issue 
with Dr. Ladd as to the cause of ventral 
hernia following incisions in the abdomen. 

He says that ventral hernia as a sequence 
of operations on the abdominal wall is of- 
tenest due to incomplete coaptation of the 
edges of the fascia. I would suggest that 
the experience of a large number of sur- 
geons as collated within the last six 
months has gone to show that the most 



frequent cause of ventral hernia, following 
wounds of the abdominal wall, is the use 
of the drainage-tube or drainage. The 
fact that in one hundred and twenty-six 
consecutive operations in which there was 
no attempt to bring into coaptation the 
edges of the fascia, there was no case of 
ventral hernia, would seem to prove beyond 
any question the truth of the statement, 
that ventral hernia is not due to incom- 
plete coaptation of the edges of the fascia. 
Or, at least, that the question of coapta- 
tion of the fascia itself had but a small 
share in the formation of ventral hernin. 
There are a great many other causes of 



18 



Society Reports. 



Vol. lxviii 



ventral hernia than the lack of 
coaptation of the edges of the wound; 
imprimis, the question of ptosis of the 
different viscera. Such cases may arise in 
old women who have suffered for years 
from large tumors, multilocular cysts of 
the ovary, cysts of the broad ligaments, 
large fibroids, and cases particularly of 
carcinoma of the viscera of the stomach, 
or of the ascending colon, where there is 
a tremendous amount of elongation or pro- 
lapse of the viscera by prolongation of the 
colon, so that the organ is let down against 
the abdominal wall, and nothing supports 
the organ except the abdominal wall. So 
soon as an incision is made through the 
abdominal wall, that support is 
taken away and no suturing can be de- 
pended upon to give sufficient elastic sup- 
port to maintain perfect coaptation. Ven- 
tral hernia may be caused by a prolapsed 
kidney, and undoubtedly the ptosis of the 
abdominal viscera is one of the most fre- 
quent causes for the sequent ventral her- 
nia after the operation on the abdominal 
wall. 

The method of suturing wounds by pro- 
longed and continuous sutures through 
the peritoneum, and ignoring the muscles 
entirely, and joining or coaptating the skin 
and suturing it, has not been followed 
particularly often by ventral hernia. Had 
the question of the occurrence of ventral 
hernia, or its non-occurrence, depended 
upon the coaptation of the fascia, then 
should ventral hernia have followed every 
one of these cases. 

Ventral hernia is a matter which, as I 
should think has been pretty well proven 
by the condition of soldiers during the late 
war to be largely conditioned upon the 
physical condition of the individual. In 
examining the 2264 inmates of the Na- 
tional Soldiers' Home last year, there were 
found forty-six cases of ventral hernia in 
men, forty of which were above the um- 
bilicus, and six below. In one case which 
was regarded as a ventral hernia, there was 
hernia following an operation on the ab- 
domen for dressing a shell-wound of the 
abdominal-wall, and, of course, we could 
get no history in regard to the operation 
or its method of treatment. This hernia 
was very large in size. 

Another point that Dr. Ladd made in 
regard to the question of the use of sutures 
is, I think, worthy of attention. I do 
not think the number of sutures is of the 



greatest importance. Dr. Senn, who cer- 
tainly has had great experience in these 
matters, and with whose operations I have 
been familiar, seldom used more than five or 
six sutures along the abdominal wall, 
which were passed directly though the 
whole thickness of the wall from within 
outward. The abdominal wall was then 
lifted by means of the sutures, and a sponge 
used to protect the intestines; this was 
removed and then the sutures were each 
separately tied. Then a few superficial 
stitches closed the wound entirely, and 
that was the end. I saw many of his 
cases after the operation and followed them 
to recovery, and saw no cases of ventral 
hernia following. My own list of laparot- 
omies is not enormously large, but I have 
never been obliged to accuse myself of 
having caused ventral hernia by neglect in 
regard to the number of stitches, and I 
seldom use more than four or five 
in an abdominal wound. If the operation 
has been done under proper aseptic condi- 
tions and has been done properly, there is 
but little chance that forty-eight hours 
will go by without there being complete 
cohesion of the peritoneal surfaces, and 
but little more is required of the stitches 
through the abdominal wall than to main- 
tain the surface in coaptation until such 
effusion of lymph shall have taken place 
and the wound has been healed from with- 
in. Therefore, I think that with each 
stitch danger increases, and that the fewer 
we use the better, Within reason. 

Dr. Solon Marks: I have seen a good 
many ventral herniae within the last forty 
years, and I look upon it that it is hardly 
necessary to stitch the fascia at all. I 
think, in the majority of cases, where the 
sutures are put through the wall entirely 
and drawn up, that union will take place 
in a short time. I think there may be 
cases such as Dr. Ladd has alluded to, 
where it is absolutely necessary to insert a 
large number of stitches, but, as a rule, I 
think the dressing, as described by Dr. 
Brown, is all that is necessary. I hardly 
believe that it is necessary to stitch those 
different fasciae separately and put in a 
great number of stitches. 

Dr A. J. Puls: I would like to call 
attention to the following points: 

First: The adhesion of the small in- 
testines to the peritoneum, can always be 
avoided by placing the omentum over the 
intestines. Second: There should be no 



January 7, 1893. Society Reports. 



19 



antiseptic solution used in the abdominal 
cavity. Wherever you apply the antisep- 
tic solution within the cavity you are sure 
to have adhesions of the intestines to the 
wound surface. Third: Abscesses of the 
abdominal wound I have not met with ex- 
cept in one case, and the fault there arose 
from my not drawing one stitch (it was 
the lower stitch) through the abdominal 
wall. As a rule, I always sew right 
through the wall from the outside, 
bringing the needle through on the inner 
side in the opposite direction, and bring 
both walls in opposition. I am always 
careful to get the muscle to come together. 
I do not care at all about the fascia ; I do 
not see it. Fourth: Take in the peri- 
toneum and the muscle and you will al- 
ways have a good, healthy wound. I have 
had occasion to open two of my wounds 
and make a second laparotomy, and I 
found an exact cicatrix which would not, 
under any circumstances, allow a ventral 
hernia. Fifth: It is advisable, in order 
to avoid the possibility of ventral hernia, 
to secure the wound for at least half a year 
with straps and bandages. 

Dr. Brown: I have had occasion to 
look up the matter of ventral hernia thor- 
oughly and particularly. I have had four 
cases within the last year upon which I 
have operated, and I would like to say a 
word in regard to fascia. I operated three 
weeks ago in this hospital (Milwaukee) 
upon a case where the laparotomy was 
followed by ventral hernia. The post- 
mortem examination disclosed a carcino- 
matous degeneration of the left Fallopian 
tube. The condition of the hernia in 
this case is of interest, particularly in re- 
lation to what Dr. Ladd has said in regard 
to the coaptation of the edges of the fas- 
cia. This woman had a ventral hernia, 
which, when she took a deep inspiration 
or contracted the abdominal wall for the 
purpose of evacuating the bowels, pro- 
truded from the abdomen as large as a 
four-quart pail, and when she stood erect 
and threw the bowels back into the ab- 
dominal cavity and held them there by a 
tense condition of the rectal muscles, the 
hernia was half as large as a child's head. 
When I attempted to get the history of 
the case, all I could find out from her was 
that she had been operated on in Portage 
two years ago. Five weeks after the oper- 
ation, the wound not being healed com- 
pletely, (she had been obliged to go about 



her household duties,) the whole wound 
got open except the peritoneal layer. She 
had been put to bed again, the edges of 
the wound brought together and junction 
had taken place, leaving behind this 
ventral hernia. I endeavored to make 
the operation by making an incision on 
the side of the tumor about the circum- 
ference of its base, the idea being to split 
the layer of tissue which covered the 
bowels, dissect out a piece of the encase- 
ment of the tumor, draw the peritoneal 
margins together and sew the semilunar- 
shaped flap back in its place, and in that 
way bring the line of the two incisions at 
different points in the abdomen, and also 
to interlace during the process of opera- 
tion the layers of muscles from the one 
side of the abdomen with the layers of 
muscles from the other. But so soon as I 
made my incision and attempted to split the 
flap I found it consisted simply of perito- 
neum, transverse fascia and the skin — 
there was no muscle there; so I was obliged 
to make a central incision, dissect off part 
of the flap and bring the edge of the wound 
together in the ordinary way. The wound 
healed perfectly, but the woman died on 
the eight day of inanition and a post-mor- 
tem examination revealed the fact that 
the intestine had become adherent — long 
before I had seen the case — to the upper 
portion of the uterus and its lumens was 
less than the size of a very small quill at 
that point. She had taken food which 
remained in the upper part of the small 
intestine, none passing through the bowels. 
She had no temperature and would have 
made a good recovery except for this con- 
traction of the intestine. It was certainly 
a case where apparently the transverse 
fascia had done something towards trying 
to save the abdominal and had not done 
it. It was impossible to draw the mus- 
cle layers of the two sides of the abdomen 
together, and there was no elastic tissue 
whatsoever of the intestine and the ab- 
dominal contents, and the hernia was 
formed. It seems to me that it is far 
more important that the muscle layers of 
the abdominal wall should be as nearly as 
possible placed in their original position 
for the sake of their elastic characters, 
than that the inelastic, unyielding, white, 
fibrous tissue of the transverse fascia 
should be restored to its place. 

Dr. Samuel W. French: In respect 
to this point of uniting fascia, I would 



20 



Society Reports. 



Vol. lxviii 



say that it calls to mind an unfortunate 
case that I had two years ago, in which I 
had the stitch abscess the doctor has men- 
tioned, and the whole wound went by the 
board. The peritoneum, however, had 
united. The wound had to be filled up 
from the bottom. I attempted about two. 
months after the operation, to refresh the 
edges and bring them together by buried 
sutures, but there evidently was some pus 
left behind, and the operation was a fail- 
ure. The patient remained in the hos- 
pital some eight months and it was eight 
months from the time of the operation be- 
fore the whole wound was healed. I saw 
the patient a year afterward and there was 
no ventral hernia. I believe that stitch 
abscesses come from dirty needles and im- 
properly prepared silk, and no matter how 
careful we may have been, that there has 
been something left behind, so much so 
that in using silk myself I sterilize my 
silk and my needles upon three successive 
days if I am going to do a laparotomy. 
But I do believe that the next time I do 
laparotomy I shall use the silk worm gut, 
and I had come to that conclusion some 
time ago. I have noticed also that 
another gentleman, a member of this so- 
ciety, who does a great deal of laparotomy 
work has also come the self- same con- 
clusion, and I understood from him the 
other day that for some little time back 
he had used nothing but silk worm gut 
for the abdominal sutures. I believe this 
course is sound, because it is perfectly 
evident that a silk worm gut is a substance 
that can be more thoroughly sterilized and 
you are surer about it than you are with 
silk or braided silk. 

De. Puls: I favor the use of silk for 
sutures. I have used silk worm gut for 
vaginal operations, and I am sorry that I 
have. I do not like it. It cuts into the 
tissue, and unless you thread it thoroughly 
it opens, and if it is too tight it will cut. 
Silk will never do that. 

The point made by Dr. French of ster- 
ilizing the needle three times before going 
through an operation is, in my opinion, 
altogether erroneous. If he takes his 
needle and thread and puts them into a 
sterilizer and leaves them there for ten or 
fifteen minutes, he will never have stitch 
abscesses, everything else being in proper 
condition, and properly done. I have 
seen gentlemen come with their needles 
prepared the night before to an operating 



room, and have heard the method praised, 
but I think it is unnecessary and wrong. 

Dr. A. J. Burgess: A practical point 
about ventral hernia is that it rarely, if 
ever, becomes strangulated. Therefore, a 
surgical operation is not always necessary. 
The treatment by bandages and trusses is 
often sufficient and certainly much less 
dangerous. 

Dr. French : If we are ready to believe 
scientific men on the germs of suppura- 
tion, it has been found that there are cer- 
tain germs of suppuration that fifteen 
minutes will not kill in the sterilization ; 
and it is therefore necessary, in order to 
be positively sure that all germs and all 
spores are killed, to sterilize on three suc- 
cessive days. 

Dr. Ladd (closing the discussion): 
This discussion reminds me of a story 
which illustrates the point so well that I 
may be excused for telling it. In a west- 
ern court a case was brought where a rail- 
road company was defendant. A farmer 
had carelessly driven across in front of a 
locomotive of the company and had been 
struck. The engineer testified that he 
blew his whistle; the brakeman testified 
that he heard the whistle blow; but the 
farmer brought in five men that testified 
that none of them heard the whistle blow, 
and the farmer won his case. I have 
never had a ventral hernia follow an op- 
eration. The fact that Dr. Brown cites 
126 cases in which it has not occurred 
proves nothing. It is the case that has 
ventral hernia that he must investigate to 
find whether the fascia are finally united. 
The case of the drainage tube would also 
be a case where the fascia was not united. 
He has not brought forward a positive 
case of ventral hernia to illustrate the 
point. I do not put three stitches to an 
inch in a wound after laparotomy. In 
my paper I refer to operating in case 
of ventral hernia. 

As to suturing the muscle, this un- 
doubtedly is important, and the ordinary 
way of applying the stitches through the 
muscle would, almost invariably, include 
the fascia, which is probably the reason 
why ventral hernia has not more often fol- 
lowed these operations. 



Foreign. — Mr. Murphy — Pwhat is lay 
greep, Mrs. Flaherty? Mrs. Flaherty — 
It's me impreshun, Mr. Murphy, that it is 
wan of thim bloody Oyetelian saysoities. 



January ?, 1893. 



Society Reports. 



21 



GYNECOLOGICAL TECHNIQUE AS CARRIED OUT AT THE GYNECEAN 

HOSPITAL.* 



J. M. BALDY, M. D. 



It is no uncommon thing to have physi- 
cians from all over the country, who are 
making a temporary stay in Philadelphia, 
and who are visiting the hospital with the 
object of seeing operations, question min- 
utely as to the different points in the pre- 
paration, and not infrequently express sur- 
prise at the simplicity of these. In fact, 
it has often occurred to me that many of 
our visitors are more interested in the 
preparation than in the operation itself. 
To one who has the success of this class of 
work at heart, this seems to be a step in 
the right direction, as it has long since 
been recognized by the successful opera- 
tor of the world, that more good results 
are obtained by mediocre operators, whose 
preparations have been most careful and 
systematic, than by their more brilliant 
colleagues who have been inclined to scoff 
at minutiae and to depend upon their me- 
chanical skill. 

Erom time to time articles on this sub- 
ject have appeared in medical print giving 
the most elaborate description of the prep- 
aration and the apparatus used, most of 
which are undoubtedly excellent and well- 
fitted for the operating-room of a hospital, 
but which are unnecessarily cumbrous 
when one comes to apply them to private 
work. For this reason I have been en- 
couraged to enter upon a detailed descrip- 
tion of our work at the Gynecean Hospi- 
tal, the application of which can readily 
be carried into private practice. The 
watchwords from the beginning to the end 
of an operation are thoroughness and sim- 
plicity. 

The aim of all successful operators is 
the same, namely — the prevention of any 
septic matter entering into the field of op- 
eration. Different operators adopt differ- 
ent methods of accomplishing this object, 
but for success, the object and result must 
be the same, whatever the method adopted 
may be. 

Antisepsis or asepsis, as fancy may dic- 
tate, the principle is the same. To be 
successful one must be surgically clean. 
For the proper accomplishment of this 
one must consider and treat: 1. The 

•-[Read before the Philadelphia County Medical 
Society, December 28, 1892.] 



patient. 2. The operating-room and its 
paraphernalia, including tables, basins, 
pitchers, buckets, instruments, ligatures, 
sponges, dressings. 3. The operator, as- 
sistants, and nurses. 

1. The patient. — The preparation of 
the patient should begin, when possible, 
at least twenty- four hours before the 
operation. The first steps are to regulate 
the diet and empty the gastro-intestinal 
tract. Free purgation is begun at once, 
preferably by the use of some saline. 
This is usually administered in the dose of 
a drachm of sulphate of magnesia, dis- 
solved in water, each hour until the bowels 
begin to move. Usually five or six doses 
are sufficient to accomplish the object. 
The purgatives should be so administered 
that the action of the bowels ceases five or 
six hours before the time set for the opera- 
tion. After beginning the administration 
of the purgative, the diet should be light 
and concentrated. If the operation is to 
be performed in the afternoon, the pa- 
tient's supper on the day before consists 
of the ordinary house diet. From this 
time on nothing passes her lips, unless it 
be a glass of milk or a cup of bouillon at 
breakfast- time. Even water, except in 
small quantities, is withheld. These 
steps in the preparation can be carried out 
in the case of most patients, but in deal- 
ing with an unusually weak woman, con- 
siderable judgment must be used in their 
application. A hot bath is given, both 
the day before and the morning of the 
operation. If the patient is unable to be 
moved to the bathtub, the baths are given 
in bed. Prior to the final bath an enema of 
soapsuds and water and a vaginal douche 
of bichloride of mercury (1 to 3000) are 
given. Immediately on coming from the 
bath a fresh night-gown is put upon the 
patient and she is placed in a bed which 
has been specially prepared for her recep- 
tion. After returning to bed the abdomen 
— the seat of the operation — is especially 
prepared. A nail-brush, soap and hot 
water are used freely and vigorously, 
special attention being paid to the umbili- 
cus and pubic hairs. In but exceptional 
cases is the pubes shaved. The abdomen 
is then bathed with alcohol and turpentine 



22 



Society Reports. 



Vol. lxTiii 



and is finally protected until the time of 
the operation with a towel wrung out of 
bichloride solution. 

When the patient is placed on the 
operating table the abdomen is well rubbed 
with ether and bathed with alcohol by the 
operator as the final preparation, especial 
attention being paid to the pubic hairs 
and the umbilicus. The legs are wrapped 
in a blanket, which extends from the feet 
to the pubes ; a second blanket is placed 
over the chest. All blankets, clothing, 
table, etc., about the patient from her 
chest to her feet are now covered with 
towels prepared for the purpose, the ab- 
domen being left bare from the epigastrium 
to the pubes. Over all this is placed a 
piece of bichloride gauze, with a slit in it 
at the point of the incision. 



In the preparation, the room is first 
stripped of all its furniture. The walls, 
ceiling, and floor are washed down with a 
hose, and then mopped off: with a cloth 
dipped in bichloride solution. As each 
article is brought into the room it is 
scrubbed with soap and water, rinsed off, 
mopped with bichloride solution, and 
placed in its proper position; the tables 
and benches are covered with sheets or 
towels especially prepared for this purpose. 
A glance at the accompanying cut will 
more clearly demonstrate this. All linen 
used in the operating-room has been 
laundried by itself. Distilled water is 
ueed throughout the operation. 

Instkuments. — After an operation the 
instruments are thoroughly scrubbed with 
soap and water, and are then passed through 




2. The Operating-room and its Para- 
phernalia. — All tables used in the opera- 
ting-room with the exception of the Krug 
frame for Trendelenburg's position, which 
is of galvanized iron, are made of wood, 
perfectly plain and shellacked. The rea- 
son for this is two-fold — first, because it is 
desirable in the preparation of the room 
that it should be emptied ; this is rendered 
possible in the case of everything except 
the gas fixture and the sink. Secondly, 
as there is an operating-room on each 
floor, it becomes necessary to frequently 
move the tables from one room to the 
other. When not in use, the windows in 
these rooms are always open. The walls 
of the room from floor to ceiling are of 
white tile, the window trimmings are of 
white marble, the floors are asphalt, the 
ceilings are plastered and heavily painted. 



scalding water before being returned to 
the case. Prior to the operation they are 
boiled for twenty minutes in a weak soda 
solution. As few instruments as possible 
are used. In an ordinary operation two 
needles, two ligature staffs, four hemosta- 
tic forceps, a knife, a needle-holder, and 
a pair of scissors are amply sufficient. 
These, are taken, together with the tray 
on which they are placed for boiling, 
directly from the sterilizer, and put upon 
the table as the patient is brought into 
the room. In this way they are not 
handled from the time they are taken out 
of the sterilizer until they are to be used. 

LiGrATUBES. — Three varieties of ligatures 
are employed — silk, silkworm-gut, and 
catgut. A half-hour before the operation 
the silk is immersed in a bichloride solu- 
tion (1 to 100); prior to being used it is 



January 7, 1893. 



Society Reports. 



23 



washed in boiling water. The silkworm- 
gut is boiled with the instruments. The 
catgut is prepared by being immersed in 
ether for forty- eight hours, soaked for the 
same length of time in a 1 to 100 alco- 
holic solution of bichloride of mercury, after 
which it is put in a solution of two parts 
oil of juniper and one part alcohol. It is 
taken directly from the latter solution for 
use at the operation. 

All sutures and ligatures used within 
the abdominal cavity are of silk (Chinese 
twist.) Silkworm-gud is invariably used 
for closing the abdominal wound. Catgut 
is used principally in vaginal hysterectomy 
and plastic work. 

Sponges. — New sponges are prepared by 
being thoroughly beaten, soaked for twenty- 
four hours in a weak solution (3 percent.) 
of hydrochloric acid, after which they are 
soaked for twenty-four hours in a strong- 
soda solution, and are finally placed in 
alcohol. Immediately after being used in 
an operation they are thoroughly washed 
in cold water, placed in a strong soda 
solution (practically a saturated solution) 
for twenty-four hours, at the end of 
which time they are removed, washed 
under the cold-water spigot until all the 
soda is washed away, and are then im- 
mersed in a solution of sulphurous acid 
for twenty-four hours. They are taken 
directly from the acid solution, washed, 
and placed in commercial alcohol until 
used. Four sponges only are used at each 
operation. 

Dressings. — The dressing of the ab- 
dominal wound consists in placing several 
strips of dry bichloride gauze directly 
over the incision, a cotton pad covered over 
with gauze placed over this, and the 
whole held in place by a six- tailed 
bandage. Dressing are not dis- 
turbed for eight days. No iodoform or 
other powder is used. Stitch-hole ab- 
scesses are the rare exception. 

Draining -tubes. — After being used, 
the glass drainage-tubes are soaked in 
strong soda solution for twenty-four hours, 
rinsed under the spigot, washed with 
turpentine and ether, and then boiled for 
twenty minutes, after which they are 
kept in commercial alcohol. 

Rubber drainage-tube, whenever used, 
is soaked in bichloride solution, and washed 
in boiling water. 

After an operation the drainage-tube is 
cleaned by the nurse every fifteen minutes 



or half-hour, as occasion requires. As 
the fluid discharged from the tube lessens 
in quantity, the intervals of cleaning are 
lengthened. Each time the tube is cleaned 
the nurse's hands are carefully prepared 
with soap and water and bichloride solu- 
tion. 

At and after each cleaning the syringe 
used to withdraw the tube-contents is 
cleaned inside and out with hot water and 
bichloride solution, as are also the mouth 
of the tube and the rubber protecting it. 
Fresh bichloride cotton is placed over the 
entrance of the tube at each cleaning. The 
tube is removed as soon as the contents 
become clear and small in quantity. The 
edges of the opening left by the tube are 
drawn together by a strip of adhesive 
plaster, and the dressings replaced by 
fresh ones. 

3. The Operator, Assistant and Nurses. 
— Everbody who takes part in an opera- 
tion, and is liable during its performance 
to handle any of the instruments or ma- 
terials, is required to go through the same 
preparation. All assistance is rendered 
by three nurses ; the chief nurse assisting 
the operator directly, a second nurse 
attending to the sponges, and a third 
nurse changing the waters. The prepar- 
ation of operator and nurses is as follows : 
a hot soap bath, and clean linen clothing 
direct from the wash. The hands and 
arms are prepared by first carefully clean- 
sing the nails with a penknife, a free use 
of hot water, soap, and nail-brush for 
twenty minutes, and rinsing in fresh 
water. They are then bathed in commer- 
cial alcohol, and are finally soaked in a 
bichloride solution (1 to 2000) for five 
minutes. The greatest danger-point of 
infection is, of course, under the nails, 
and time used in a most careful hand 
toilet is never misspent — is, in fact, abso- 
lutely essential to success. 

A careful study of the cut, which rep- 
resents one of the operating-rooms as it 
appears prior to the introduction of the 
patient, will demonstrate the simplicity 
and thoroughness of all the preparations. 
There is not an article in the room which 
cannot be duplicated or easily substituted 
in any well-ordered household. Soap, 
water, nail-brush, and bichloride of mer- 
cury tablets are easily obtained, and as for 
the remainder it rests entirely with the 
surgeon and his nurse. With a little 
more time and trouble the poorest hovel 



24: 



Society Reports. 



Vol. Ixviii 



can be turned into a good and safe opera- 
ting-room, by adopting these rules, as I 
have been able to demonstrate time after 
time in my work in the slums of this 
great city. Of course, it means plenty of 
hard labor for both nurse and surgeon, 
but what nurse or surgeon who has once 
passed through the horrors of attendance 
at a death from septic peritonitis 
would not feel that the work before 
the operation was as nothing in com- 
parison to that afterward. 



The number of instruments, sponges, 
etc., may seem to many to be entirely in- 
adequate for the purpose, but in many 
hundreds of operations we have found 
them amply sufficient ; it is the rare ex- 
ception that recourse to the instrument- 
case is necessary. The fewer articles used 
the fewer sources of possible infection and 
accident. A large number of instruments 
lying about are, in addition, a source of 
endless confusion and annoyance, and they 
require an extra assistant. 



Haemorrhoids. 



In an article concerning Reconstruc- 
tion of the Pelvic Structures in Women," 
Dr. H. Marcy, of Boston {American 
Journal Obstetrics, for November), writes : 

The pathological conditions which per- 
tain to the rectal tissues result in very 
large degree from changes in the vascular- 
ization, dependent upon the dilation of 
the hemorrhoidal veins. These are often 
deformed to an extent rarely appreciated 
by the ordinary practitioner, and only to 
be truly understood by the surgeon who 
makes the vivisection for the purpose of 
cure. 

I am constrained to believe, as I think 
for abundant reason, that the ligature and 
cautery, destruction of the tissues by acids, 
etc., are not alone unsurgical and barba- 
rous, but they also often fail in the end of 
securing the desired result, since a portion 
of the deformed structures not seldom 
remain unchanged, and tissues of im- 
portance to preserve are thereby frequently 
destroyed. 

A complete dissection of the deformed 
haemorrhoidal plexus, as advocated by Mr. 
Whitehead, offers in my judgment abun- 
dant reason for adoption, and the only 
criticism which I have to make unon his 
method is the closure of the wound with 
interrupted sutures. This method has 
been severely criticised, and has failed in 
great measure of general adoption becaase 
of the fear of hemorrhage which during 
the indefinite pass has been emphasized as 
liable to pertain to any of the methods 
applicable to the cure of haemorrhoids. 
This is doubtless greatly overestimated by 
the profession at large. 

The dilatation of the haemorrhoidal 
plexus is, indeed, sometimes truly enor- 



mous, but it will be found upon dissection 
that the vessels quite within the grasp of 
the sphincter are usually very little 
changed, and that here their constriction 
is simple and easy. I have for some years 
operated in a way to be commended as in 
large measures bloodless and assuredly 
without danger of subsequent haemorrhage. 

The procedure is briefly as follows : The 
sphincter muscle is dilated and the parts 
put on tension by two fingers in the 
rectum. Either with a sharp knife or 
scissors division is made upon the line of 
the juncture of the skin and mucous mem- 
brane. With a little care the veins are 
separated from the loose folds of connec- 
tive tissue without injury, down to the 
line of the sphincter muscle. They will 
be found closely connected with the everted 
thickened mucous membrane, a portion of 
which it is well to remove. Division 
should be made through it upon the line 
selected for incision, and a row of contin- 
uous double tendon sutures is rapidly 
made to encircle the base of the haemor- 
rhoidal plexus. It is then resected with 
scissors, and a light line of continuous 
running sutures encloses the deeper layer, 
and when drawn upon gently, taken, as 
advised, from within outward, are them- 
selves buried, thus leaving no stitches in 
sight. Carefully dried and dusted with 
iodoform, the operation is completed by 
painting the line of closure with a layer of 
iodoform-collodion. It is usually better 
that three or four days elapse before 
defecation ensues, after which there is 
little suffering. With the paralyzed mus- 
cle at rest, the condition of the parts re- 
maining aseptic, pain and edema are 
almost wanting. — Md. Med. Journal. 



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Saturday, January 7th, 1893. 



EDITORIAL. 



With this issue The Medical ato Sur- 
gical Eeporter enters upon its forty-first 
year of continuous publication. Every ef- 
fort will be made to meet the growing de- 
mands of modern medical journalism and 
at the same time retain the highly practical 
character that has always distinguished this 
magazine. There are in the field to-day 
medical journals and medical journals, but 
few in which the effort is made to supply 
the profession with accurate, reliable in- 
formation of the progress of the science 
and art of medicine and surgery. 

The many intersperse clippings from 
the few between columns of a gorgeous 
variety of advertisements. Advertising 
incidental to medicine is a factor in 
progress. Medicine incidental to advertis- 
ing is clap- trap. The Medical aistd Sur- 
gical Reporter has always been one of the 
few and has acquired to a rare degree the 
confidence of the profession. It will never 
knowingly sacrifice nor impair this trust. 

As its name signifies its mission is to 
report as far as possible the latest and 
best achievements in the whole field of 
medicine and surgery. The evolution of 



medical science has so developed along 
special lines that it is manifestly impossi- 
ble for any one journal to cover in detail 
all branches of medicine and surgery and 
remain within reasonable limits. 

The busy practitioner demands infor- 
mation that he can immediately turn to 
practical use. Where his opportunities of 
frequent association with large bodies of 
his fellow practitioners are limited he 
must depend on his journals for informa- 
tion that will enable him to keep abreast 
of the times. 

The general practitioner, who to a cer- 
tain extent is a specialist in all lines, has 
not the time to read, if he has the means 
to procure, special journals for each branch. 
Recognizing this condition The Medical 
an-d Surgical Reporter will in the 
coming year supply periodically a series of 
monographs. These will be in the form 
of supplements to the regular editions of 
the magazine. Each monograph, written 
by a specialist eminent in his line, will be 
devoted to one subject treated in greater 
detail than is practicable in the regular 
columns. Another feature will be a care- 



26 



Editorial. 



Vol. Ixviii 



fui review of the contents of the best 
special periodicals under a department of 
Current Literature Eeviewed. In the mat- 
ter of Book Eeviews an impartial critical 
statement will be made. This department 
will be conducted for the information and 
advice of the readers of the Eeporter 
wholly independent of other considera- 
tions. The Editorial Department will 
maintain an independent position, free 
to discuss or comment on such matters as 
may be of interest to our patrons. 

The Eeporter will not be subservient to 
any individuals, cliques, or institutions 
whatever, but will be solely of the pro- 
fession, for the profession, by the pro- 
fession. 

A word to our advertisers — no advertise- 



Dr. C. D. Palmer (Neiv York Medical 
Journal) says: 

The symptoms of such a condition are 
principally attacks of pain, coming on gen- 
erally about the middle of the intermen- 
strual period, and most severe in the 
region of the ovaries. Sometimes the pain 
is confined to one ovary, or both may be 
involved in the paroxysm. The attacks 
are irregular in severity and duration, 
usually intermittent, occurring at night 
or through the day. Their duration may 
be from two to nine days. They are not 
influenced by bodily exertion nor attended 
by febrile phenomena. As to the cause of 
such ovarian pain, neuralgia has been 
suggested as a probable factor, but, if this 
be the case, why is it that pain does not 
occur during the regular menstrual period, 
as at that time women are especially suscept- 
ible to pelvic pains? The periodicity of 
the pain first led to a suspicion of malarial 
poisoning in these cases, but this theory 
was soon abandoned when it was found 
that the attacks were not at all influenced 
by the most potent antiperiodics. I am 
not inclined to think there is a structural 
change in the ovary to account for the 
pain, although the form, size, or even 
density of the organ may not be so altered 
as to make the change discoverable before 



ments are admitted to our columns except 
such as after keen scrutiny we feel satisfied 
are perfectly reliable. That an advertise- 
ment does not appear in The Eeporter is 
no measure of its value, but one that does 
appear in its pages may be regarded as per- 
fectly reliable. 

The policy of The Eeporter which bars 
promiscuous advertisers is not such short 
sighted f business as might appear. Our 
advertisers have learned the value of a 
medium that possesses the confidence of 
its readers, and The Eeporter sees no 
reason to doubt the wisdom nor to change 
the course heretofore pursued. The Ee- 
porter commends to the kind considera- 
tion of the profession every interest repre- 
sented in the advertising spaces. 

removal. The condition may be an 
oophoritis, a peri-oophoritis, and inter- 
stitial oophoritis, or a follicular oophoritis, 
or several of the tissues may be involved 
in the degenerative process. There is 
likely to be hardening of the organ, which 
interferes with the rupture of the follicle ; 
this may be one cause of pain. There is 
no reason why the pain may not occur 
before the menstrual flow, on account of 
the increased vascularity of the ovary at 
such a time. The severity of the pain 
may be out of proportion to the pathologi- 
cal change and nerve pressure. "When the 
congestion subsides, the pain is usually 
relieved. Various measures have been re- 
sorted to for giving relief, some of which 
have been more or less effective tempo- 
rarily. In some cases, however, the suf- 
fering will be of such character, and the 
life of the woman be made so miserable, 
that the question is forced on the gyne- 
cologist whether it would not be the proper 
thing to remove the ovaries in such a case, 
even though to the touch they seem nor- 
mal. 



Syphilis, after a number of years in the 
system, becomes detritus — not the disease 
per se — and needs a solvent plan of treat- 
ment, not a germicidal. 



Periodical Intermenstrual Pains. 



January 7, 1893. 



Translations. 



27 



TRANSLATIONS 



POST-OPERATIVE INTESTINAL OBSTRUCTION. 



MARIE B. WERNER, M. D. 



Championniere reports six cases treated 
Lccessfully by operation. (Bull, et mem. 

la soc. de chirur. cle Paris T. xviii 
ige 102). 

1st Case. Ovariotomy; patient set 35. 
^our days after the operation symptoms 
)f obstruction set in, gradually increasing 
m severity. Reopening the abdominal 
wound on the tenth day various coils of 
intestines are found to be adherent to one 
another, one being twisted twice, forming 
a circular constriction around another. 
Carefully releasing the adhesions, the ab- 
domen was closed, followed two hours 
later by a copious bowel movement. Re- 
covery. 

2nd Case. Radical operation for incar- 
cerated gangrenous omental hernia. The 
patient did well up to the 14th day, after 
that violent abdominal pain set in, vomit- 
ing and increased temperature. Vomit- 
ing increased until it became fascal in 
character. Abdomen distended above the 
umbilicus where a circumscribed hard mass 
could be felt. Second operation done on 
the 21st day. A large abscess was found 
surrounded by intestines and covered by 
the omentum; drainage and recovery. 

3rd and 4th Case. Radical operation 
for left inguinal hernia; recovery takes 
place; pains, however, appear in the right 
inguinal region, accompanied with moder- 
ate swelling, vomiting and constipation. 
Four weeks after the operation it became 
necessary to make an incision over the 
right inguinal canal. A small amount of 
fluid is evacuated, but the intestines are 
seen to be adherent to the swelling, which 
made it advisable to open in the median 
line and approach the swelling from the 
inside. This proved to be an incarcerated 
loop at the internal inguinal ring which 
had become almost gangrenous. Close to 
this there was also an abscess. The 
median incision was closed; the one on 
the right was tamponed . Recovery. 

Two and a-half months later symptoms 
of ileus again set in. Laparotomy; in- 

*Translated for Medical and Surgical Reporter. 



cision over the right inguinal canal and 
release of many dense adhesions. The 
day following, a copious movement. The 
abdomen^ however, increased in disten- 
sion, making it necessary to perform in- 
guinal colotomy. Recovery; discharged 
with fistula. 

5th Case. Radical operation for a con- 
genital left inguinal hernia with resection 
of a large portion of the omentum. Case 
progressed favorably until the ninth day 
when symptoms of ileus set in; constipa- 
tion, vomiting and fever, 38.8° C. A 
painful swelling can be felt in the right 
iliac fossa. On the nineteenth day an in- 
cision is made into the swelling, a large 
amount of extra vasated blood is evacuated, 
the sac cleansed and drained ; rapid recov- 
ery. 

6th Case. Herniotomy for incarcerated 
intestines. A small perforation was dis- 
covered and closed; healing. After a 
time colicky pains; constipation and tym- 
panitic distension of the abdomen ap- 
peared. These symptoms increased until 
there was no doubt of its being caused by 
ileus. Laparotomy; that portion of the 
gut which had been sutured was found 
tightly adherent to the abdominal wall, its 
calibre markedly lessened by its angular 
position. In order to avoid enterorhaphie 
Championniere dissected the intestine 
from the abdominal wall leaving both 
peritoneal coats intact at the points of ad- 
hesion ; recovery complete. 

Championniere is decidedly opposed to 
the administration of opiates in any form 
after any abdominal operation. He is par- 
ticularly anxious to have an early action of 
the bowels and in certain cases has been 
known to give laxatives on the evening of 
the day of operation, and feels certain it will 
rather lessen than favor the danger of per- 
itonitis, in that early peristalsis often pre^ 
vents incarcerations, adhesions or paralysis 
of the intestine. He also condemns the 
use of opiates in cases of strangulation of 
the bowel, feeling certain that the early 
exhibition of laxatives has often led to 
an earlv diagnosis. 



28 



Abstracts. 



Vol. lxviii 



A Case of Living Xiphopagus, 

Hr. Marcel Bandowin reported in the 
Paris Acadeniie of Sciences the case of 
two girls of three years and two 
months, being united from the xyphoid 
process to the umbilicus in the regio 
snb-umbilica. They were born in the 
East Indies, and make the eighth case of 
xiphopagus reported. A careful examina- 
tion proved that neither presented in- 
versis viscernm; which proves that the 
lower division of the true xiphopagi and 
thorakopagi have been properly described 
by Dareste who presented their origin 
in the following manner. If in one 
ovum two fertilized nuclei develop in a 
parallel line at the same time, a doable 
monstrosity results, the xiphopagus; both 
primitive lines must at first be distinct- 
ly separate, one at each pole of the 
ovum; when the embryos, well developed, 
become larger, they face each other 
and the upper regions of the body come 
in contact. Surgical treatment in these 
cases is advisable. In fact, indicated, 
for should one of the sisters become 
fatally ill the chances of saving the 
other would be greatly lessened. Even 
should there be union of the liver, ad- 
hesions or even anastomosis of the in- 
testines (which is not improbable), the 
operation might produce a doubly good 
result. 

It has been performed several times (?) 



by Kcenig with a good result an d ce 
by Boehm-Gunzenhausen, on his own 
daughter, with partial good results; the 
one living five years after the operation. 



Resection of the Left Lobe of the 
Liver for Cancer. 

Prof, von Licke (Central-Matt. f. Chir- 
urg. 41, 1892) reported in the Centrabl. f. 
Chirur.'91, 'No. 6, p. 115, this case in detail 
and wishes to report the present condition 
of the patient. Two years have elapsed 
since the operation, the patient has been 
constantly under observation, and fre- 
quently examined. During the past sum- 
mer she became much emaciated, and suf- 
fered from loss of appetite and frequent 
vomiting and distension in the gastric re- 
gion ; a return was suspected ; the cicatrix, 
however, was healthy and the most careful 
examination disclosed no tumor of either 
liver or stomach. By exclusion it was 
concluded that her emaciation and its 
concomitant symptoms was due to her im- 
poverished circumstances, the good diet 
and care she received with her visible im- 
provement in strength and weight seemed 
to substantiate our conclusions. 

At the present time a careful examina- 
tion proves the total absence of any return 
in the organ operated upon for more than 
two years. 



ABSTRACTS. 

CHOLERA EPIDEMIC OF 1892. 



In an editorial retrospect of the past 
year the Boston Medical and Surgical 
Journal says: 

In recent years, when cholera has 
reached Europe, it has generally come by 
the way of the Suez Canal. This was the 
case in the outbreak in 1890, in Spain. 
In 1891 no cases was reported in Europe. 
It had, however, come through the Red 
Sea ports into the Hedjaz, during religious 
ceremonies in Mecca, and had spread 
through Asia Minor. In the first of the 
year cases still occurred in different parts 
of Asia Minor, but by the middle of Feb- 
ruary it has disappeared from the neigh- 
borhood of Damascus and Bey rout, and 



existed only in one or two interior valleys. 
This year the religious pilgrimage to Mecca 
was not attended by cholera. 

The epidemic of this year appeared in 
March, in the northwestern provinces of 
India. It is obligatory on every Hindoo 
to bathe in the Ganges where it issues 
from the mountains. The dying Hindoo, 
also, is immersed in this stream, if it is 
possible to get him there, and this point 
is always considered a cholera focus. The 
water this year was very low, and the 
bathing-place was reduced to a pool. On 
March 22d the first case occurred at 
Hurdwar, and on the 25th the fair was 
closed by the police authorities. Thedis- 



January 7, 1893. 



Abstracts. 



29 



ease was spread by returning pilgrims 
through the Punjaub, and reached Delhi 
on March 30th. From here it spread 
through the Cashmere Valley, and reached 
Afghanistan on April 15th, and it reached 
Persia in May. In June it crossed the 
Caspian Sea, and in July spread among 
the population of Asiatic Russia. By the 
middle of the month it reached the Cau- 
casus and crossed into European Russia. 
It was at this time especially virulent at 
Teheran and Astrakhan and in the Cauca- 
sus. It advanced steadily through Russia, 
reaching Moscow and St. Petersburg by 
the middle of July. Until this time no 
cases had been reported west of Russia 
except in Paris and these cases in Paris 
were not a part of the invading epidemic. 
From April 5th up to July 25th about 160 
deaths from a rapidly fatal diarrhoeal af- 
fection had been reported in the neighbor- 
hood of Paris, and the character of the 
disease, although attributed to the nse 
of Seine water, and manifesting itself in 
those quarters where that water is supplied 
for consumption, bore such a striking 
resemblance to Asiatic cholera, that its 
identity was during the whole summer a 
subject of dispute. This disease, which 
was popularly called cholerine, had existed 
as an endemic outbreak to a less extent in 
previous summers. In the autumn, after 
cases of undoubted Asiatic cholera had 
occurred in northern France, the attempt 
to distinguish between the two diseases 
was abandoned,. 

In regard to the origin of the cholera in 
Hamburg, Havre and Antwerp, nothing 
positive is known. The infection of Ham- 
burg may have come by rail through 
Germany, with Russian immigrants on 
their way to America, or it may have 
come by sea from Russia or from India. 
All of these suppositions were discussed. 
The authorities of Hamburg discovered 
the true character of the disease on the 
2 2d of August, and announced it on the 
24th. It was found to exist in Havre and 
Antwerp within a few days of the same 
time. During the next week isolated cases 
made their appearance in many cities, the 
cases being almost all easily traced as im- 
ported from Hamburg. Several cases oc- 
curred in Berlin, some in other North Ger- 
man cities, some in different English sea- 
port towns, all of the latter being in per- 
sons directly from Hamburg. Such iso- 
lated cases continued to occur during the 



first half of September, diminishing in 
frequency. In Hamburg the epidemic in- 
creased very rapidly and with a great 
mortality. Although the highest point 
in mortality was reached in the week end- 
ing September 3d, when 4,168 deaths, of 
which 3,710 were from cholera, were re- 
ported, making a death-rate of 340.8, 
nevertheless, for some time the decline was 
slow, but after the last week in September 
fell rapidly. In Havre the epidemic was 
not nearly so great, the number of cases a 
day about the first of September being 
from 25 to 100. 

The extension of the epidemic crossed 
the Austrian frontier some weeks later, a 
few hundred cases being reported, especi- 
ally in Austrian Poland. It appeared in 
Buda-Pesth early in November, and con- 
tinued into December. In the whole 
Austrian Empire 1,000 cases and 500 
deaths may be estimated as the number 
during the autumn. On November 1st, 
Hamburg was declared free from cholera, 
but in November four deaths occurred and 
in the last half of December a fresh out- 
break occurred, about forty cases being re- 
ported up to the present time. The official 
statistics in October gave the number of 
cases as about 18,000 with 7,600 deaths. 
In Havre, the number of cases from July 
15th to October 15th was given as 1,298, 
and that of the deaths 523. This includes 
a few cases which were later classed as 
cholera although occurring before the out- 
break was recognized. During November 
a few cases were reported from different 
parts of France, 104 in Holland, 33 in 
Belgium, whereas in Germany there were 
none except the four in Hamburg. In 
Russia the epidemic was much more 
serious and persistent, many districts were 
revisited after the epidemic had apparently 
declined. After the 1st of November the 
disease as a whole was much less serious 
in the Empire, but the total number of 
cases reported remains considerable even 
up to the present time. The estimate of 
300,000 deaths is commonly considered as 
less than the actual fact. The efforts of 
the sanitary authorities were very much 
hampered by popular uprisings and in 
some cities serious riots occurred in conse- 
quence of the attempt to enforce sanitary 
regulations. 

Cholera was imported into the New 
York quarantine directly from Hamburg. 
The first infected steamer to arrive, the 



30 



Abstracts. 



Vol. lxviii 



Xormaiinia, left Hamburg just before the 
official announcement of the existence of 
an epidemic. Within a week two more 
steamers, the Moravia and Eugia, and 
latter the Scandia, reached New York 
thoroughly infected. The number of 
deaths at sea had been 63 and a still larger 
number were either suffering from the 
disease on arrival or came down with it 
shortly afterwards in quarantine. The 
number of passengers detained from this 
cause was very large, far beyond the ca- 
pacity of the New York quarantine sta- 
tion. After keeping the cabin passengers, 
who with a few exceptions had been free 



from cholera, for several days upon the 
infected ships, a steamer was hired by 
private liberality to accommodate them, 
and Fire Island bought as a place of de- 
tention. The inadequacy of the quaran- 
tine station and the bungling of the whole 
matter may be understood by following 
the subject as it appeared from week to 
week in the Joubnal. A few cases, a 
dozen or more, with five deaths occurred 
in the city; their source is doubtful but is 
more probably due to contagion introduced 
by passengers from an earlier steamer 
which sailed from Hamburg ou Aug. 14th, 
than that it escaped from the quarantine. 



INTESTINAL OBSTKUCTION: SOME CURIOUS OASES. 



George Buchanan, Professor of Clinical 
Surgery in the University of G-lasgow, in 
The British Medical Journal says : 

" Diseases of the rectum are, of all sur- 
gical affections, among those which are 
most frequently neglected in their early 
stages, and so are allowed to assume a con- 
dition of considerable gravity before treat- 
ment is resorted to. This arises from 
various causes. Many persons, especially 
females, have great disinclination to have 
that part of the body made the subject of 
observation and examination, till compelled 
by their suffering to resort to a medical 
opinion ; at least, that has often happened 
in my experience. Again, many imagine 
that all disorders of the intestinal tract 
arise from indigestion, biliousness, or hab- 
itual constipation, which they imagine can 
be removed by the use of familiar laxative 
medicines, and these they use with all dil- 
igence till they prove ineffectual; and if 
by pain and other discomfort they feel 
that there is something wrong at the 
lower end of the bowel, they assume that 
it is a "touch of the piles/' which can 
be cured by some of the pills and oint- 
ments so frequently advertised. One can 
scarcely take up a newspaper, especially 
provincial, colonial, or American, without 
observing the numerous advertisements of 
remedies vaunted as cures for such ail- 
ments ; and I believe that the extensive 
use of these remedies arises from the dis- 
inclination, to which I have referred, to 
submit these complaints in the first in- 
stance to the regular practitioner. 

But while this is so, not infrequently 



neglect of radical treatment can be traced 
to errors in diagnosis, sometimes, though 
not always, the fault of the medical atten- 
dant, who is apt to be thrown off his 
guard by erroneous descriptions of the 
symptoms given by the patient. One or 
two examples of this will follow. 

The term "intestinal obstruction" in 
the present day is used rather vaguely. 
Under it are included cases presenting 
symptoms, or groups of symptoms, which 
are present when there is real occlusion of 
the intestinal tube, but which are some- 
times present when there is no actual ob- 
struction at all, but which depend on 
some functional deficiency, such as loss of 
the peristalic action of the bowel, either 
with or without flatus; of that I have 
seen several instances. In a discussion 
which took place in the Medico- Chirurgi- 
cal Society of Glasgow last winter on in- 
testinal obstruction, numerous examples 
of spontaneous recovery were cited, and 
some of these in circumstances which 
precluded the idea of there having been 
even temporary local occlusion of the 
tube. I mention these to point out that 
such instances were not recoveries from 
actual intestinal obstruction, but from 
symptoms identical with those of that 
condition. 

Taking the term in its strict etymologi- 
cal sense, the most constant and obvious 
symptom is inability to pass f seces ; but in 
the great majority of cases, symptoms of 
far graver import come on, long before 
that is of any importance. It is just in 
cases in which these serious symptoms, 



January 7, 1893. 



Abstracts. 



31 



such as obstinate vomiting and failure of 
the vital powers, are early prominent, 
that spontaneous recoveries have been 
most frequent. It is also this fact that 
renders the question of operative inter- 
ference so difficult to decide. 

The foregoing observations, which are 
applicable to intestinal obstruction gener- 
ally, are more or less illustrated in the fol- 
lowing examples : 

Case 1. Symptoms of Obstruction: 
Peritonitis with Effusion : Abdominal 
Section : Recovery. — Some years ago I was 
called to see a domestic, aged about 30, 
suffering acute symptoms of intestinal 
obstruction, which had come on rather 
suddenly after a heavy meal some twenty- 
four hours before. Pain in the abdomen ; 
obstinate vomiting, stercoraceous ; cold 
skin, flagging pulse ; no flatus. I could 
not form any accurate diagnosis, but felt 
satisfied that there was no course open to 
me but abdominal section. No obstruc- 
tion could be found, but the peritoneal 
cavity was full of acrid greenish effu- 
sion, and the bowels partially glued 
together with recent lymph. I washed 
out the cavity with a stream of tepid 
water. The patient made a rapid recov- 
ery and is now the mother of a family. 

Case II. Symptoms of Obstruction: 
A bdominal Section: No Discoverable Cause: 
Death. — Lady, aged about 20, with symp- 
toms somewhat as above, but not so rapid 
or acute. There was no flatus, but the 
vomiting was continuous and non-sterco- 
raceous. I performed abdominal section. 
There was no obstruction; the intestines 
were quite flaccid, and contained very 
little fluid; and the peritoneam was quite 
healthy. She died next day. 

Case III. Symptoms of Obstruction: 
Apparent Failure of Enemata followed 
shortly by Relief, and Recovery. — An old 
gentleman with symptoms of intestinal 
obstruction. Constipation had existed for 
some days, and now there was pain in the 
abdomen, flatus, and obstinate vomiting. 
I examined the rectum and washed it out 
■with tepid water, using a long tube and a 
forcing pump. There was no evidence of 
any f fecal impaction, the water returning 
as it was introduced. I could not find 
any abnormal condition of the intestinal 
tube, but, the symptoms becoming more 
grave, I proposed abdominal section as a 
last resort. The patient agreed, but asked 
me to bring in consultation a physician 



with whom he was acquainted. T did so 
and we agreed that, if he should have the 
same opinion the operation should be done 
at his visit. I returned with my friend 
three or four hours after, when to my sur- 
prise I found my patient greatly relieved. 
He had had a copious evacuation in the 
interval, and the vomiting had ceased. 
He made a rapid and good recovery. 

Case IV. Obstruction^ Suspected Epi- 
thelioma: Removal of Impacted Fceces: 
Rapid Recovery. — A lady, 30 years of age, 
troubled with constipation for some time, 
accompanied with much pain in the rec- 
tum. Latterly, the pain in attempting 
defsecation was so great that, practically, 
she had passed nothing for some time but 
discolored mucous and sometimes blood. 
For some days she had been troubled with 
vomiting whenever she took any nourish- 
ment. Her medical attendant, discover- 
ing that the symptoms arose from some 
obstruction in the rectum, endeavored to 
make an examination, but the pain was 
so great, that the patient would only allow 
a very partial exploration to be made, 
either per rectum or per vaginam. Enough 
was felt to lead to the opinion that the 
rectum was occluded by an epithelial 
growth, which extended far up the gut 
and bulged the recto-vaginal septum into 
the vagina. Some surgical operation 
was urgently demanded — either excision 
of the rectal tumor, or the making of an 
artificial anus. As the patient could not 
suffer a preliminary examination, it was 
arranged that I should put her under 
chloroform, make a thorough examination, 
and proceed as I might find matters re- 
quired. 

The patient was placed on a 
table, and put under chloroform. 
On introducing my finger into the re- 
turn I found it occluded by a large mass 
of firm unyielding material, either adher- 
ing to or firmly grasped by the walls of the 
bowel. But it had not the feel of an 
epithelioma. It was smooth and globular. 
I could not tear it with my finger, and 
there was no channel through it for faeces 
to pass through, and it did not bleed. I 
had no doubt it was a mass of hardened 
faeces, and the smell from my finger nail 
made it certain. I now with my thumbs 
dilated the sphincter ani as far as it would 
stretch, and, getting a horn spoon, tried 
to lever it out. It was too large and firmly 
fixed for that. The medical practitioner, 



32 



Abstracts. 



Vol. lxviii 



who lived in the adjoining house, went for 
his obstetric bag, and I chose a long, nar- 
row-bladed fenestrated forceps, which is 
used in craniotomy. I passed a blade on 
each side, and, by putting on firm traction, 
removed a large gobular mass of firm, 
tough material as large as a full sized 
orange. Another mass as large as a tur- 
key's egg was impacted above that, and 
was removed in the same way. A third 
the size of a hen's egg was impacted still 
higher up, and that was also removed, and 
the passage was cleared. I now injected a 
basinful of soapy tepid water, which came 
away with a few bits of scybala. The 
patient was practically well, and she has 
remained so ever since. 

Case V. Obstruction due to Impacted 
Fceces. — A man who had had symptoms of 
obstruction for some time, but only on the 
dav I saw him had vomiting come on. 
The medical attendant believed that the 
rectum was obstructed by an epithelial 
growth, and called me to perform some 
operation for its relief. On examination I 
found that the rectum was blocked by an 
enormous mass of hardened fasces. As the 
house was not suitable for operations and 
the symptoms were not dangerous, I gave 
a subcutaneous injection of morphine, and 
ordered the patient to be sent to the West- 
ern Infirmary, and next morning, broke 
up and removed the mass, which was 
about the size of two closed fists, 

Case VI. Obstruction due to Impacted 
Masses of Calcined Magnesia. — A case 
which occured some years ago, I mention 
from the unusual nature of the obstructing 
mass. It was composed of hard masses, 
the size of walnuts, with facets caussd by 
long mutual pressure. They were con- 
cretions of calcined magnesia, which the 
patient had long been in the habit of using 
as a laxative. 

We caution against allowing patients to 
use calcined magnesia habitually. 

It is not often that an opposite error of 
diagnosis occurs, but the following case is 
a good illustration : 

Case VII. Diagnosis of Epithelioma: 
Revised Diagnosis of Intestinal Atony: 
Recovery. — A middle-aged gentleman, of 
sedentary habits, had for many months 
suffered from some anomalous symptoms 
— indigestion, flatulence, occasional vomit- 
ing, and obstinate constipation alter- 
nating with looseness, the stools being of- 
ten simply discolored mucous. His medi- 



cal man had ordered some tonic remedies 
for dyspepsia; but, as he did not improve, 
he consulted a surgeon with whom he was 
personally acquainted. The surgeon ex- 
amined him per rectum, and told him that 
he had an epithelial growth far up; that 
it was out of reach of any operation for its 
removal; that there was no hope of his 
recovery; that his progress downward 
would be gradual ; but that at no distant 
date he must decide whether he would 
submit to undergo an operation for the 
formation of an artificial anus or await 
his end, which could not be very far off. 
His medical attendant was unable to ac- 
quiesce in this opinion, and, before ac- 
cepting it, brought him to me. I made a 
most careful exploration of the rectum, 
but I could find no growth, stricture, or 
any kind of obstruction ; indeed, the mu- 
cous membrane seemed to me more flaccid 
and folded than usual, and in one of the 
folds I felt a small piece of hardened 
fasces, which seemed adherent or retained 
in the fold. I came to the conclusion 
that the symptoms arose from atony of 
the intestinal tube from end to end, with 
possibly some softening, in parts, of the 
mucous lining, and specially of the lower 
end of the colon and rectum. I recom- 
mended that he should give up business 
for two or three months and go to Spa iti 
Belgium, and gave him a letter to my 
friend Dr. Thomson, indicating my opin- 
ion and the treatment I thought would 
benefit him. The result proved more for- 
tunate than I could have anticipated from 
the use of the chalybeate waters and the 
change of climate and diet. My patient 
came home practically well, and has con- 
tinued so ever since: that is, for more 
than two years. 



A large percentage of the candidates for 
admission to the military schools of Amer- 
ica are rejected on " tobacco hearts." 

In chronic suppurative otitis, so long- 
as the offensive odor continues, the treat- 
ment is not succeeding. 

French medical observers are of the 
opinion that the offspring of inveterate to- 
bacco users often greatly lack the normal 
power of resisting disease, chiefly through 
the transmission of defective nervous sys- 
tems, and that they are largely deficient 
in physicial development. 



January 7, 1893. 



Abstracts. 



33 



THE EQUITABLE RESPONSIBILITY OF INEBRITY. 



In the Journal of Nervous and Mental 
Diseases, December, Dr. T. L. Wright in 
a carefully prepared paper on this subject 
states that he selects the term inebriate 
responsibility because there is no settled 
responsibility for the acts of mere 
drunkenness. 

Drunkenness is a form of insanity and 
is practically so recognized by the law. 
There is no definition of insanity, nor can 
there be. The sane cannot- conceive the 
insane ; and hence it cannot define the in- 
sane. It can only describe phenomena; 
but it is unable to point out the logical 
connections between the phenomena of in- 
sanity and their moving cause. The rule 
of responsibility for inebriates differs in 
civil from that in criminal cases. We will 
consider the responsibility of inebriates for 
criminal acts. 

"The law assumes that he who, while 
sane, puts himself voluntarily into a con- 
dition in which he knows he cannot con- 
trol his actions, must take the conse- 
quences of his acts,and his intentions may 
be inferred." What class of inebriates is 
it that most frequently violates the laws 
of the land — and particularly those laws 
that relate to crimes of violence ? Clearly 
that class that drinks the most immoder- 
ately, the most irrationally, the dipsomani- 
cal class. 

Dipsomania is a mental disease. The 
convulsive or spasmodic drinking of 
the dipsomaniac is only one of the traits of 
the malady — showing that the insanity, no 
longer latent, has become active and 
raging. Magnan says: "The alcoholic 
excitement with which an attack of dipso- 
mania terminates, should not be con- 
founded with dipsomania itself, as it is a 
complication, not a symptom of it." 
Trelat also says: "Dipsomaniacs are 
patients who become intoxicated whenever 
their attack comes on." But who is the 
dipsomaniac? Always he is one of the 
neurotic constitution. He is in a state of 
hypnotic automatism much of the time, 
not only when intoxicated, but the strong 
presumption is, that he labors under 
the same disability at the very 
moment when he begins to consume 
alcohol in order to become drunken. This 
is inconsistent with the idea free-will, or 
rational volition. Drunkenness is not al- 



ways, if it is ever, a factor or a part of dip- 
somania, but may be a consequence of it. 
The dipsomaniac cannot be assumed to be 
"sane"; and in drinking he does not 
" voluntarily " put himself in a condition 
in which he "knows "he cannot control 
himself. On the contrary, the dipso- 
maniac being insane, cannot control him- 
self when — and before — he begins his un- 
governable movements of intoxication. 
His drinking is one of a series of causes 
tending toward crime — the first one of 
which was formed in an insane mind ; and 
for the existence of which the inebriate 
mind is totally irresponsible. 

It is true that the uncertainties, imper- 
fections, and necessities of human nature, 
make it incumbent on society to hold, 
within certain limits, even the insane re- 
sponsible for criminal acts. Sometimes 
the presumed knowledge of right and 
wrong, abstractly, is made the test; or, 
whether the insane criminal knew that a 
particular act " was wrong," may be chosen 
to determine the measure of his responsi- 
bility. Nevertheless the assigned limits 
of insane responsibility are narrow, and 
often difficult to establish. It is prob- 
able that true dipsomania may sometimes 
be of such moderate intensity that it 
should not be excused from accountability 
for criminal deeds. Again, the mental 
disease may be more severe, and grave 
doubts may arise as to the rightfulness of 
holding it responsible for inebriate mis- 
conduct. But there are instances wherein 
the violence of dipsomanical insanity is 
superlative; and there can be no question 
as to the injustice of exacting responsibil- 
ity for its conduct. And now the scene of 
strife is reached. To distinguish accur- 
ately the truly responsible, the doubtful, 
and the wholly irresponsible among dipso- 
maniacs themselves, is the work in hand. 
In view of the facts of dipsomania, it seems 
unjust and untrue to declare that drunk- 
enness is no defence for crime. In strict 
accordance with the legal maxim already 
cited, dipsomania does, in all cases, pre- 
sent a good prima facie defence for 
criminality. The reasonable mind, the 
sober mind of the dipsomaniac has nothing 
to do in deciding upon the probabilities of 
intoxication; for the intoxication of dipso- 
mania is only of a series of more or less 



34 



Abstracts. 



Vol. lxviii 



insane movements, begun and carried on 
under the forceful suggestions of mental 
disease. As long as the insanity is latent 
there is no drunkenness. The crave for 
drink is, in the dipsomaniac, the outcome 
of disease, and of unmanageable nervous 
distress. 

The powers of mind are overcome and 
dominated by a peculiar form of insanity; 
and the will, in all such contingencies, is 
latent, or powerless. It must be borne in 
mind that the question here is not of the 
actual commission of crime, but that it re- 
lates to the voluntary establishment of the 
criminal propensity through the act of 
drinking. 

Similar considerations apply to the 
character of criminal responsibility in the 
habitual drunkard. In him, incurable 
physical degenerations have impaired the 
integrity of important organs. Structural 
degradations of the gravest import atfect 
perhaps, the liver, or kidneys, or brain. 
These may serve as centres of irritation to 
the entire nervous organism ; and to allay 
this, a crave for the lethal effects of alco- 
hol may become overmastering. Here is 
the incentive to drink till the full alcoholic 
influence is established. Degenerations 
within the brain materially interfere with 
sound judgment and rational discrimina- 
tion. Here is incapacity to reason on the 
wisdom and the moral nature of conduct. 
Will, too, is inefficient and helpless, be- 
cause the diseased appetites and impulses 
of the animal being are stronger than the 
determination of rational choice — and they 
rule the life while reason slumbers. The 
rigid responsibility demanded for so-called 
alcoholic crime should be somewhat miti- 
gated in view of the fact that alcohol alone, 
is rather infrequently the exciting cause 
of criminality. Recent intoxication is 
generally agreeable. The mind is elated 
and happy. It is mainly after prolonged 
inebriation that the surly and truculent 
disposition, often attributed to simple 
drunkenness, appears, Then it is that 
strange poisons other than alcohol, have 
become present in the circulation. It is 
then that carbonic acid, urea, and other 
poisons not alcoholic oppress the brain, 
and force the mind into vicious thoughts 
and incentives. Under circumstances of 
this kind, alcohol should not be charged 
with the sole agency in the formation of 
the criminal nature; it is only one of 
many. 



When the material instruments of the 
mental and moral powers are, for a pro- 
tracted season, inhibited in function by 
the anaesthetic property of alcohol, great 
disturbances must ensue in the manifesta- 
tions of mind and morals. Anaesthesia 
withdraws the nervous centres from spon- 
taneous activity and compels the mind to 
assume that inferior plane of exhibition, 
which is merely imitative, habitual, auto- 
matic. It is impossible for a mind in 
which the sense of personality is wavering 
or destroyed to so establish its own rela- 
tions with morality as to be capable of dis- 
tinguishing accurately between right and 
wrong. To perceive what is right requires 
alertness and the intellectual power of 
clear discrimination. To recognize wrong 
requires the same mental properties, and 
also a sensitive condition of the moral 
faculties — which is quite inconsistent with 
the torpor imposed by alcoholic anaesthesia. 
The questions often propounded in courts 
of law respecting the moral capacity of 
criminals are in substances these: "Could 
the man distinguish between right and 
wrong? Did he know when he committed 
the act, that he was doing wrong?" These 
questions embody what the courts in Eng- 
land and America insist shall be a real 
test of legal responsibility for crime. But 
the power of discriminating between the 
fine shades of the moral qualities must 
be weakened when consciousness is defec- 
tive; and it must be defective in some de- 
gree in every grade of anaesthesia. The 
law recognizes the fact that the man 
drunk is insane. There is actually, and 
founded upon the incontrollability of the 
mind in drunkenness, a remarkable legal 
inference, to the effect that drunkenness 
is no defence for crime. True, this has 
the appearance of a strange inconsistency; 
for the law also declares that " where there 
is insanity, that can be no crime." The 
legal conclusion respecting responsibility 
for inebriate crime involves an assumption 
that may be disputed. " The law has 
settled that a drunken intent is just as 
guilty as a sober one." This may be 
settled as law, but it is not settled as fact. 
There is no pretence that the law has 
proven the equality, or even the similarity, 
of a drunken and a sober intent. 

The perfect mind cannot conceive of 
itself as being insane. The drunkard does 
not believe that he cannot control his ac- 
tion when drunk — although he cannot. He 



Jammry 7, 1893. 



Library Table. 



35 



knows nothing of hypnotism, nor of in- 
vading poisons, unexpected and unknown. 
The sober ego is wholly different from the 
drunken ego. The body is the same, but 
the minds are two. A sane mind, may 
speak for another mind also sane; their 
faculties are on the same plane of consci- 
ousness, by reason of a similar pre- 
sentation of surroundings. But a sober 
mind cannot speak for itself as though 
drunken. The differing states of the 
mind cause it to act as two ; and they can 
no more explain the motives and interpret 
the movements of each other, than a sound 
mind in one person can interpret the im- 
pulses of an unsound mind in some other 
person. 

Respecting the criminal responsibility 



of the man who drinks from mere idle- 
ness and without any driving, neurotic 
stress, and who is free from congenital 
and from constitutional defects — the latter 
arising from disease or injury — and who 
is free from the physical degenerations of 
habitual drunkenness, no doubt the rules 
of accountability should be strict. But 
even in such instance, principles of re- 
sponsibility should not be "lumped" or 
generalized. The effect of alcohol is so 
modified by special nervous sensibilities 
and peculiarities, that it is the right 
of every individual guilty of inebriate 
crime, to have his trial made a special 
one. He is entitled to a full inquiry 
respecting the facts that pertain to himself 
alone. 



THE LIBRARY TABLE. 



Hygienic Measures in Relation to Infectious Diseases. 
Comprising in Condensed Form Information as to 
the Cause and Mode of Spreading of Certain Dis- 
eases, the Preventive Measures that should be re- 
sorted to, Isolation, Disinfection, etc. By George 
F. Nuttall, M. D., Ph. D. New York: G. B. Put- 
nam's Sons, 1893; 112 pp. $1,50. 

The author first gives a general discussion 
on the various methods of disinfection, by 
means of fire, dry heat, steam, chemicals 
etc., together with precautions to be followed 
by the physician, the nurse, care of the sick 
room, etc., and then describes the methods as 
applied to each one of 31 diseases. The plan 
of the w ork will be best seen if we take a 
specific example. 

IV DIPHTHERIA. 

Cause: Bacillus diphtheria ,• obligatory parasite. 

" The infection is spread through the bacilli in the 
sputa, false membrane, and secretions of the various 
diseased mucous membranes. The bacilli are proba- 
bly present at times in the stools. Physicians and 
nurses are particularly exposed to the danger of the 
infection when swabbing the throats of patients, 
through the coughing of mucous and flakes of mem- 
brane into their faces. Lesions of the mucous mem- 
braces where no susceptibility exists predispose to in- 
fection. The diphtheria of pigeons, calves, pigs, (not 
determined in the case of cats) is not to be feared as a 
source of human diphtheria, the diseases being due to 
different specific agents. 

As the bacilli resist drying they may be scattered 
about in the form of dust. In thin layers the bacilli 
withstand drying for fourteen days, whilst in pieces 
of membrane, clothing, particularly in dark, damp, 
and cold places, they may retain their virulancefor four 
to seven months. A temperature of 58°C. (136° F.) 
kills them in ten minutes. They apparantly die in a 
few days in putrifying substances. The bacilli multi- 
ply at 18° C. (64° F.), and milk being an excellent 
medium for their growth, the milk of dairies in a vicin- 
ity where the disease prevails may be a carrier of the 



infection and promote the development of the infec- 
tious organism. 

PREVENTIVE MEASURES 

Complete isolation of the patient is necessary as 
long as the slightest trace of the membrane is present, 
and for sometime after it disappears. Children should 
be kept from attending school at least four weeks after 
the disease has disappeared. Where the disease pre- 
vails, Loeffler maintains the importance of keeping the 
mouths, noses, and throats of healthy children clean, 
using for this purpose an aromatic or other wash every 
three or four hours; sublimate 1 to 10,000 or 15,000; 
cyanide of mercury, 1 to 10,000; chloroform water, etc. 
For the patients he recommends a gargle every two to 
three hours of the nature recommended above, together 
with a stronger one used at longer intervals; namely, 
sublimate 1 to 1,000; 3 per cent, carbolic acid in 30 
per cent, alcohol; or equal parts turpentine and alcohol 
containing 2 per cent, carbolic acid — Virulent bacilli 
could not be found after a few days when this treat- 
ment was followed, whereas they are to be found 
usually after three weeks when the ordinary treatment 
is pursued. Special precautions should be taken when 
using poisonous solutions in the treatment of children. 

DISINFECTION. 

At the end of the book is found an account 
of the methods of surgical disinfection, pre- 
paration of the patient, of the operator, 
dressings, etc., followed in the Johns Hopkins 
Hospital. 

There are few men in the country who have 
had the theoretical training and practical ex- 
perience in this line of study, which Dr. 
Nuttall has had, in the laboratories and hos- 
pitals of Europe and America, and who can 
place so much information upon the subject 
of disinfection, etc., in so short a space and 
in so few words as is done in this short book. 
There is really no book which covers exactly 
the same ground which this book does in so 
concise a manner and without lengthy theo- 
retical discussion 8. 



36 



Library Table. 



Vol. lxviii 



A Treatise on Diseases of the Rectum, Anus, and Sig- 
moid Flexure. Joseph M. Matthews, M. D. With 
six chromo lithographs and numerous illustrations; 
Handsomely printed and bound: pp. 537. New York: 
D. Appleton <fc Co. Sold only by subscription. 

The title of this book, and the author's 
name, are almost sufficient introduction to 
the public. 

There are many books. Some should never 
have been written, but it would be well if we 
had more such practical and thoroughly val- 
uable works, as the one under consideration. 
Prof. Matthews is one of the able surgeons of 
America who has devoted his time and study 
to diseases of the rectum. He has reached 
success and eminence. 

This work illustrates the radical changes 
that surgery has undergone more fully than 
any other that we have seen. The author 
gives his opinions in a most positive and 
decided way, dealing exclusively with the 
present. Iii addition to the regular subject 
matters of works of this class, the author has 
introduced many new subjects, viz: Diseases 
of the Sigmoid Flexure; antisepsis in rectal 
surgery, etc. 

Among the many good things that com- 
mend the book, we notice the sound ad- 
vice on diagnosis. " I believe that the most 
important thing connected with medicine or 
surgery, is a correct diagnosis of disease." 

Dr. Mathews strongly insists on a thor- 
ough examination of the patient who com- 
plains of rectal trouble. Without this, a 
correct diagnosis cannot be made, and with- 
out a full knowledge of the conditions, treat- 
ment cannot be pursued intelligently. The 
chapter devoted to the diagnosis and treat- 
ment of constipation is exhaustive, clean and 
original, showing the results and experience 
of a observant mind. The plates and illustra- 
tions are clear and accurate. The work 
throughout is a classical presentation of 
a varied personal experience. 

While it should be thoroughly appreciated 
by the specialist, it should particularly com- 
mend itself to the general practitioner. 

The style and artistic work of the book 
are characteristic of the well known firm of 
Appleton & Co. 



Materia Medica, Pharmacy, Pharmacology and Therein 
peutics. By W. Hale White, M. D., F. R. C. P., 



Physician to, and lecturer on Materia Medica and 
Therapeutics, at Guy's Hospital, London: Examiner 
in Materia Medica to the Conjoint Board of Eng- 
land; Author of a Text book of General Therapeutics. 
Edited by Reynold W. Wilcox, M. A., M. D , LL. D., 
Professor of Clinical Medicine at the New York Post- 
Graduate Medical School and Hospital; Assistant 
Visiting Physician to Bellevue Hospital; Fellow of 
the American, and of the. New York Academy of 
Medicine, etc. 8vo, 607 pages. Cloth, $3.00. Pub- 
lishers: P. Blakiston, Son & Co., 1012 Walnut Street, 
Philadelphia. 

The text is well arranged, the definitions 
are comprehensive and statedin terse lan- 
guage, while the divisions are clearly drawn. 
The appendix of non-pharmacopeal remedies 
is an useful addition; all the better known 
new remedies are described. In arrangement, 
the work is somewhat like the well known 
w orks of Potter and Wood. The art of pre- 
scription writing receives attention; phar- 
macology is very fully considered and greatly 
adds to the value of the work. 

A busy physician has no time to go into 
deep researches. What he wants is fact, and 
this is what we see in the book before us. 



A Manual of the Practice of Medicine. Prepared es- 
pecially for students, by A. A. Stevens, A. M., M. D. 
Instructor of Physical Diagnosis in the University of 
Pennsylvania, etc. Illustrated. Philadelphia: W. 
B. Saunders, 1892. Small 8vo. Pp. 501. Price, 
$2.50. 

An examination of this book shows it to be 
a work that is useful, not only from its ow n 
merits but it also presents in condensed form 
the views of many authorities on the sub- 
ject. 

The author has done his work in a thor- 
ough manner. Especially is this true when we 
note how T he dwells on symptomology, and 
the relations of various symptoms to each 
other. The treatment given, is brief, yet in 
accordance with the accepted method of to- 
day. The definitions are clear, concise and 
exact while the pathology and etiology are 
equally lucid. 

Yet it is to be remembered that works of 
this class should not prevent the student from 
referring to more comprehensive authorities. 
As collateral reading we know of none better 
than the book before us. 



CURRENT LITERATURE REVIEWED. 



AMERICAN JOURNAL OF MEDICAL SCIENCES. 

The January number contains the following 
articles: — " The Albuminuria and theBright's 
Disease of Uric Acid and of Oxaluria." 

Dr. DaCosta discusses those cases of Bright's 
disease originating in excessive uric acid for- 
mation or in oxaluria, reviewing the symp- 
toms of a malady in which digestive disorder 
occurs, aud in which the disturbed nutrition 
manifests itself in the urine, chiefly by the 



high specific gravity, the urates and the pres 
ence of albumin and casts that are commonly 
thought to indicate Blight's disease. He re- 
marks that dyspeptic symptoms are rarely 
absent, though they may be very slight. The 
circulation is prone to be irregular, sometimes 
rapid, sometimes slow. Rigidity of arteries, 
or even tension, which is said to belong to the 
uric acid diathesis as well as to the contracted 
kidney, he has rarely noted. The hypertro- 
phies and other cardiac lesions of Bright's 



January 7, 1893. 



Current Literature. 



37 



disease are absent, as are dropsy and eye le- 
sions. A symptom worthy of note is the 
slight rise of temperature in the afternoon. 
The characters of the urine are very signifi- 
cant. There is the high specific gravity in a 
urine that is about the normal amount', or, a 
little scantier than normal. The urine, on 
standing, deposits urates, sometimes even 
uric acid, very often mucous. Crystals of ox- 
alate of calcium may take the place of the 
urates or alternate with them. The total solids 
are increased. The amount of albumin is gener- 
ally small, varies much with the time of day, 
and is mostly in the morning urine or that 
voided after breakfast. Casts are scanty or 
altogether absent. In character they are hy- 
aline or epithelial, rarely markedly granular, 
never fatty. 

The main difficulty of diagnosis is to dis- 
tinguish between beginning contracted kid- 
ney and this affection. In advanced cases 
there is no difficulty. The doctor believes 
that the instances of diatetic albuminuria 
reported are in reality cases of this affection, 
as are also those cases where the albumin ap- 
pears after severe exertion. The form of al- 
buminuria under consideration may be met 
with at any age. It is rare among ' children 
and old persons. It is common in growing 
boys. As is Blight's disease it is much more 
common in the male. 

The prognosis is favorable, though the 
cases may be of long duration, with occa- 
sional reappearance of albumin in the 
urine. Yet, from very long continuance of 
the disorder, fibroid changes may take place 
and interstitial nephritis result. 

The pathological state is essentially a con- 
gestion of the kidney, with— should' the hy- 
peremia persist— slight local inflammatory 
changes in the vascular cortex from the irri- 
tating effects of excreting increased amounts 
of ill-formed or broken-down tissue, in the 
shape of urea, urates, or, these imperfectly 
oxidized, as oxalates. 

The treatment must not be that of Blight's 
disease, as commonly understood, but largely 
that of the underlying state, a state that 
we are familiar with as lithemia, or as 
oxaluria. The labor of the kidneys must 
be lessened, as in Bright' s disease, by close 
attention to diet. Green vegetables and fruits 
are freely allowed; tea, coffee, and cocoa are 
permitted, if sweetened but slightly. The 
white meat of poultry and game may be 
moderately taken, but the meats containing 
much nitrogen are forbidden. Milk has not 
been found especially useful. Sugars, and 
those vegetables containing sugar, are to be 
avoided. As in all forms of albuminuria, it 
is important to keep the kidneys flushed out 
by the use of pure water or the various diur- 
etic waters. Alcoholic drinks ought to be 
avoided. Bathing is clearly indicated, and 
of the good results of moderate exercise in the 
open air the reporter has seen many strik- 
ing examples. Among medicines, laxatives 
are very important. A course of muriate of 
ammonia, or, from time to time, of iron, is rec- 
ommended. In the cases with oxalates, nit- 
ro-muriatic acid remains a standard remedy. 
We must not overlook the heart, and may 



have to meet any irregularity it exhibits 
from the heavy work thrown on it, by the use 
of digitalis and strychnia. 



''Tenotomy by the Old Method." 

In this paper Frederick Treves forcibly 
presents the claims of the open method of per- 
forming tenotomy; as by this means the op- 
erator can be certain that the proper constrict- 
ing bands have been severed. The operation 
was abandoned because an open wound was a 
terror to the surgeon, a condition of things that 
has happily ceased under modern antiseptic 
methods. If a tendon can be easily and cer- 
tainly divided through a small skin puncture, 
as the tendo Achillis, then there can be no rea- 
son for employing a larger incision. On the 
other hand, if the position of the tendon or 
band be such that its subcutaneous division is 
attended with the very least uncertainty, then 
it should be freely exposed by turning back a 
suitable flap of skin. 



" Tuberculous Pericarditis." 

Prof. Osier writes: — Tuberculosis follows 
hard on rheumatic fever as a cause of pericar- 
ditis. Tuberculous pericarditis is not limited 
to any age, and is due, in a majority of in- 
stances, to infection of the membrane from 
caseous mediastinal glands. The disease may 
be confined to these glands and to the peri- 
cardium. A second, less common, mode is 
from the pleura or from the lung, and, lastly, 
there are instances in which the pericardium 
appears to be involved with the pleura and 
peritoneum in a general tuberculosis of the 
serous membranes. 

Morbid Anatomy. — Practically there are 
two groups of cases: those with firm adhe- 
sions between the pericardial layers, usually, 
with great thickening; and those with recent 
exudation, fibrinous, sero-fibrinous, hemor- 
rhagic, or purulent. The cases with adhe- 
sions are most numerous. Both layers are, 
as a rule, uniformly thickened. In other 
cases the process is more local , and the synechia 
may be limited to the front of the heart, leav- 
ing large portions of the base and of the' left 
auricle free. There is enlargement of the 
heart, which may reach an extreme grade. 
In the cases with effusion there may be a 
simple plastic exudate, similar to that in 
rheumatic pericarditis, with little, or no effu- 
sion, and with scarcely any thickening of 
the membrane, the eruption of miliary tuber- 
cles, alone, indicating the nature of the pro- 
cess. More commonly there is extensive sero- 
fibrinous exudate consisting of flakes of 
lymph, and a turbid serum. In some cases, 
the exudate is hemorrhagic, and the mem- 
branes here may be deeply engorged, and 
hemorrhagic foci be seen in them. The color 
of the effusion may be bright red, but is more 
commonly a reddish-brown or chocolate. 

In the clinical history, four groups of cases 
may be recognized: 

First, Latent tuberculous pericarditis; the 
disease being discovered accidentally. 

Second. With symptoms of cardiac insuffi- 
ciency following the dilatation and hyper- 



38 



Current Literature. 



Vol. lxviii 



trophy consequent upon chronic adhesive 
pericarditis. The clinical features are really 
those of cardiac dropsy. 

Third. Acute tuberculosis. The clinical 
picture may be that of an acute tuberculosis, 
either general or with cerebro-spinal manifes- 
tations. 

Fourth. Cases with symptoms of acute 
pericarditis. This group, the most important 
in many respects, includes cases in which the 
pericarditis is acute and accompanied with 
more or less exudate of a sero-fibrinous, hsem- 
orrhagic, or purulent nature. Here, too, the 
process may be latent. 

The diagnosis of tuberculosis pericarditis is 
extremely uncertain. In the large group of 
cases in which the membranes are thickened 
and united, the difficulties are those which 
pertain to the recognition of adherent peri- 
cardium. If there has been no history of 
rheumatism, and, if there are indications 
elsewhere, of tuberculosis, aprobable diagnosis 
can be made. In the cases that set in as 
acute pericarditis, unless there are evidences 
of tuberculosis in other parts, a diagnosis can 
rarely be made. 

Treatment. It is not improbable that tu- 
berculosis of the pericardium, may, like that 
of the peritoneum, recover completely. A 
case, that has set in acutely, must be dealt 
with as any other form of pericarditis, the in- 
dications being to limit the intensity of the 
inflammation and to prevent the evil conse- 
quences of the presence of a large amount of 
fluid in the sac. We have no medicinal 
agents at our command which have any pos- 
itive influence in controlling the ordinary 
inflammation of serous membranes. There is 
one measure on the utility of which we may 
rely, namely the ice-bag, applied continu- 
ously over the prseeordium. It allays the 
pain when present, and appears to check the 
tendency to effusion; while under its use an 
exudate may be absorbed with rapidity. It 
is much to be preferred to blisters or the 
thermocautery. Where patients complain of 
the cold, Letter's coil may be used with run- 
ning water of the proper temperature. 
When the effusion reaches a certain grade, 
and the pulse is irregular and feeble, the 
color becoming bad, the respirations hurried, 
paracentesis should be performed, or, if nec- 
essary, the sac freely incised and drained. 

"The Tampon in Menorrhagia" by Wil- 
liam T. Lusk, M. D., of New York. 

In this paper he urges the claims of the 
tampon in those cases of menorrhagia in 
which there is no definable cause for the 
bleeding and in which the curetta, uterine 
drainage and internal remedies fail to give 
relief. The method of applying the tampon 
receives due attention. 



"Methods and Results in Cases of Tuber- 
cular Disease, Aneurism, Ununited Frac- 
tures, and Head Injuries," by J. William 
White, M. D. 

The cases are for the most part taken from 
the last eighteen months service of Dr. White 
at the University Hospital, and include Tu- 
bercular Arthritis, Tubercular Adenitis, 
r eated by the removal of the glands and by 



the injection of an iodoform emulsion. The 
report also contains an account of five cases of 
Aneurism which were treated by compression 
in some cases and ligation in others. The 
paper also discusses excision of the elbow, of 
which eight were performed. One case of 
Lupus of the face w T as cured by Tuberculin. 
Delayed union and ununited fractures, with 
the various operations resorted to in their 
treatment are discussed, together with the 
several cases. Head injuries — All depressed 
fractures whether simple or compound are 
elevated. The report includes eight cases of 
trephining, of which six recovered. 
The paper is to be continued in the next issue. 



"The Cholera of 1892 in New York: its 
Prophylaxis and Treatment," by Reynold W. 
Wilcox. 

"History of the Recent Outbreak of Epi- 
dermic Cholera in New York." 

"The Bacteriological Examination of the 
recent cases of Epidemic Cholera in the City 
of New York," by Edward K. Dunham. 

In these three papers the recent outbreak 
of Cholera is reviewed in its different lights 
and the measures taken for its prevention and 
treatment are fully discussed. The report on 
the bacteriological examination of the dis- 
charges is illustrated by wood-cuts of the va- 
rious appearances of the cultures at the dif- 
ferent stages of development. 



UNIVERSITY MEDIO L MAGAZINE. 

The most important practical article in 
December's issue, is the one offered by Dr. 
Traill Green, "Ergot and the Abstetric 
Forceps." Dr. William Carpenter's paper "A 
Clinical Study of the Gonococcus " received 
the prize offered for the best clinical study of 
a surgical subject by a member of the grad- 
uating class, University of Pennsylvania, 1892. 
The question raised and the point sustained, 
by careful microscopical and laboratory work, 
is — as to whether Menorrhagia is always 
associated with an individual microorganism, 
which either by its form, grouping, color, re- 
action, method of growth, or inoculation, or 
by all these characteristics combined, is so 
distinctly different from all other bacteria, 
that with absolute certainity it can be re- 
garded as the cause of the disease, and that 
when discovered it constitutes an absolute 
proof of the presence of true gonorrhea." 
Dr. Wood in a " Memoranda " entitled " Notes 
on Quinine Idiosyncrasies " calls attention to 
two remarkable cases of cinchonism. 



N. Y. JOURNAL OF GYNECOLOGY AND 
OBSTETICS. 

An uncommonly good paper, is a 
translation of Professors Crede and Leo- 
pald's treatise, "The Obstetric Examina- 
tion," by Dr. Edgar. The subject is well 
illustrated, and considered under two heads, 
external and internal examination. 

Dr. Allen Thomas gives a brief statistical 
report of and remarks upon a period of Ob- 
stetrical Service at The New; York Emi- 
grant Hospital. Several other articles of 
minor importance complete the December 
issue. 



January 7, 1893. Periscope. 

PERISCOPE. 



39 



THERAPEUTICS. 



Salol has at last been obtained in solution 
as a pleasant, palatable liquid. Elixir of 
salol as described, is a solution by mechanical 
means only, of o grs. of salol in each dessert- 
spoonful making a palatable liquid, the ad- 
vantages of which can be clearly seen in the 
fact that it renders administration of salol 
very easy, especially to children and those 
who can not take powders or pills. — Medical 
Era. 



Paraldehyde. 

This remedy is considered in a paper in 
"Notes on New Remedies." Summing up 
in the briefest possible form what has been 
said about the properties of paraldehyde, it 
is found : 

1. That it is an efficient and safe hypnotic. 

2. That it is sometimes effective where 
chloral hydrate fails. 

3. That it is free from injurious action on 
the vital functions. 

4. That it even facilitates the digestion of 
fibrin. 

5. That in proper dosage it may be pre- 
scribed without apprehension. 

6. That it is conveniently and agreeably 
given in mixture form. 

Evidences of no little weight of the general 
usefulness of paraldehyde is afforded by the 
fact that it has been adopted into the Ger- 
man, Italian and the British Pharmacopeias. 

It should also be reorded that, in common 
with many other sedatives, paraldehyde also 
has been recommended as an antidote to 
strychnine poisoning. — Med. Rev. 



Some Internal Uses of Chloroform. 

We find the following in the Memphis 
"Medical Monthly:" In gastralgia with 
dilatation of the stomach, in the treatment 
of nervous vomiting, and of the vomiting of 
pregnacy, chloroform water in the dose of a 
small teaspoonful every half hour or hour, is 
a very useful remedy. 

In false croup, employed in the proportion 
of one to ten drops in an ounce of water, to 
which is added a little glycerine ; dose, one 
teaspoonful every half hour ; the effect is a 
very happy one. 

In ulcer of the stomach, small doses of 
chloroform given internally will often remove 
the pain and stop vomiting. 

In the treatment of whooping cough, three 
to six drop doses of chloroform in syrup will 
bring about very good results. 

In the albuminuria and anasarca of preg- 
nacy, chloroform in twelve to twenty drop 
doses in sweetened water causes a rapid di- 
minution in the albumin and the disappear- 
ance of the anasarca. — Med. Rev. 



Use of Ipecacuanha in Uterine Inertia. 

Drapes says this remedy in simple atony of 
the uterus is a powerful agent in producing 
uterine contraction during the first and sec- 
ond stages of labor. In general, two or three 
doses of from ten to fifteen drops of the wine 
of ipecacuanha, given at intervals of ten 
minutes, produce in a short time marked 
activity of uterine action and a rapid birth. 
It is much better than ergot, as it does not 
produce tetanic contraction, but only induces 
normal and regular expulsive efforts. — Med. 
Rev. 



Who Owns the Prescription? 

This has been answered by a Cincinnati 
court as follows (Meyer Bro's Druggist): 

" A druggist is under no obligation to fur- 
nish a copy nor to permit any one to make a 
copy of prescriptions. When he has com- 
pounded a drug and delivered it to the proper 
party, the paper upon which the prescription 
is written becomes his. Druggists keep pre- 
scriptions for their own protection. If, as 
the plaintiff testified, defendant had agreed 
to furnish plaintiff with a copy whenever he 
called for it, that agreement was gratuitous 
and without consideration and therefore 
void." 

This is in accord with other decisions 
which we have published. 

How would it do for druggists to print this 
decision on the back of their prescription 
blanks? — Med. Rev. 



Aristol. 

Nearly all drugs, whether or not originally 
intended for external use, have been applied 
at one time or another, to local, exterior trau- 
matisms in the once current belief that reme- 
dies that are good within should be good 
without. The conspicuous failure of the 
many attempts to obtain a perfect dressing 
for suppurative conditions which should be 
equally good for accidental or operative inju- 
ries constitutes an interesting section in the 
history of surgery. Even the latter surgical 
dressings have, for the most part, proved 
failures in some essential quality. Some of 
them possessed an unspeakable odor, others 
were toxic, many were difficult of applica- 
tion, and a further series, though admirably 
adapted to a particular surgical requirement, 
failed as complete surgical dressings. The 
promptness, for instance, with which Aristol 
was adopted by practitioners demonstrated 
the great, existing need of an adherent, 
stimulating, safe and effective cicatrisant. 
The evidence thus far appears to demonstrate 
that Aristol has not disappointed the profes- 
sion in any of these particulars. — Miss. Med. 
Monthly. " 



40 



News and Miscellany. 



Vol. lxviii 



MEDICINE. 



Treatment of Catarrhal Sore Throat. 

Dr. Carter mentions a number of remedies 
for this class of cases which should be se- 
lected according to the variety and degree of 
inflammation present, and the condition and 
idiosyncraeies of the patient. Hot wine gar- 
gles are recommended by some. Menthol, 
being an antiseptic and local anodyne, is 
useful, contracting the capillaries and*eheck- 
ing secretions. In dry, cold weather, when 
the mucous membrane is parting with its 
moisture, which is nature's covering cloud, 
treatment with vaseline spray acts well. 
Cream and ice are particularly valuable in 
children who cannot use spray or gargle. 
The essential oils, by spray or nebulization, 
are also valuable in these dry forms. Solu- 
tions of chlorate of potash and permanganate 
of potash and other astringents are useful in 
this form of sore throat, when the secretion is 
profuse. They may be used either as spray 
or gargle. Where^the secretions are too al- 
buminous, or where there is a tendency to 
the formation of penlicles on the tonsils, a 
spray of peroxide of hydrogen is indicated. 
Verba reuma, by atomization, is sometimes 
very valuable. In nearly all cases where 
there is general febrile disturbance, aconite 
and belladonna are invaluable. — Jour, of 
Am. Med. Asso. 



Tuberculous Ulcers of the Stomach. 

Dr. J. H. Musser ( Medical Press and Cir- 
cular) says: 

1. Tuberculous ulceration of the stomach is 
rare. 

2. It occurs more frequently in ehildern. 

3. It is never primary. 

4. Gastric infection is probably due to the 
voluntary or involuntary swallowing of spu- 
tum. 

5. The presence of the bacillus tuberculosis 
is the only positive proof of the nature of the 
ulceration. 

6. The anatomical peculiarities of this form 
of ulceration include the following: 

The seat of the ulcer is in the lesser curva- 
ture, although it may be found in any posi- 
tion. 

More than one ulcer is usually seen. 

The ulcers are large and irregular. 

Miliary tubercles on the floor of the ulcer, 
in the submucous coat, are seen. 

The ulcers are near vessels, and the results 
of vascular ulceration are found. 

Small caseating masses are seen in the 
ulcer or at a portion of the periphery. Simi- 
lar collections are found in the territory ad- 
jacent to the ulcer, in the submucous coat. 

The peritoneum is studded with miliary 
tubercle very often. 

Neighboring lymphatics are often in- 
volved. 

7. In the large majority' of cases, there were 
no symptoms during life. 



8. Sudden haemorrhage is a frequent symp- 
tom and cause of death; it has been particu- 
larly noted in children. 

9. Epigastric pains and vomiting may oc- 
cur. 

10. The presence of gastric symptoms of 
this kind, oecuring in the course of tuber- 
culosis, is significant of possible ulceration. 

11. In view of the fact that the swallowing 
of sputum is posibly dangerous, expectora- 
tion should be insisted upon in adults and 
its method taught to children. — Amer. Lan. 



NEWS AND MISCELLANY. 



Dr. Robert Crawford, of Cooperstown, 
Venango Co., Pa., died at his home on Chris- 
mas morning after an illness of theee or four 
days. Dr. Crawford has been in active prac- 
tice for over fifty years; was a very able man 
and stood among the leaders in the profession 
for a generation. 



ARMY AND NAVY. 



FROM DECEMBER 18, 1892, TO DECEMBER 31, 
1892. 

Leave of absence for fifteen days, to take 
effect on or about January 11, 1893, is hereby 
granted Captain W. B. Banister. Assistant 
Surgeon, U. S. Army. 

1st Lieut. Frank T. Meriwether, Assistant 
Surgeon, is relieved from further duty at 
Fort Adams, Rhode Island, and assigned to 
duty at Madison Barracks, New York. 

The Leave of a bsence granted Captain Loui^ 
W. Crampton, Assistant Surgeon, U. S. Army, 
is extended three (3) months. 

By direction of the Secretary of War. two 
months ordinary leave of absence, is granted 
Captain Marcus E. Taylor, Assistant Surgeon. 
U. S. Army, to take effect upon the expira- 
tion of his present sick leave. 

1st. Lieut. James D. Glennan, Assistant 
Surgeon* U. S. Army, will upon his arrival at 
his station (Fort Sill. Okla. Ty. ) from leave of 
absence, proceed immediately to San An- 
tonia, Texas, and report in person to the 
commanding general Dep't. of Texas, for 
temporary duty in the field with proofs 
operating" on the Mexican border. 

The leave of absence for seven days granted 
1st Lieut, Frank T. Meriwether, Assistant 
Surgeon, U. S. Army, is hereby extended 
ten days. 

1st Lieut. Benjamin S. Ten Eyck, Assistant 
Surgeon, U. S. Army, is relieved from duty 
at Fort Leavenworth, Kansas, and will pro- 
ceed at once to San Antonia, Texas, and 
report to the commanding General Depart- 
ment of Texas for duty with the troop now 
in the field. 



1. LXVIII, No. 
ole No. 187a. 

WE 



JANUARY 14, 1893 



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ORIGINAL ARTICLES. 

W. H. Link, Petersburg, Ind. 
Object Lessons in Gynecology 41 

Frank P. Norbury, M. D., Jacksonville, 111. 
Criminal Responsibility in the Early Stages of Gen- 
eral Paralysis 4i 

CLINICAL LECTURES. 

Henry W. Cattell, A. M., M. D., 
Inflammation; Pus; Positively and Negatively 
Chemo-Lactic Substances .48 

COMMUNICATIONS. 

J no. G. Cecil, M. D., Louisville, Ky'. 
The Curette in Obstetric and Gynecological Practice 50 

SOCIETY REPORTS. 

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bam OslS ' o?Shn 8 H?«^«^ ar1 ^ K> Mills, James Tyson, and Dr. Lawrence Turnbull; Professor Wfl- 

pltersburg, Va Ho P ki as University; W. C. Van Bibber, M. D., Baltimore, Md.; W. W. Lassiter, M. D„ 

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THE 

Medical and Surgical 
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No. 1872. PHILADELPHIA, JANUARY 14, 1893. Vol. LXVIII— No. 2 

ORIGINAL ARTICLES. 

OBJECT LESSONS IN GYNECOLOGY. 

W. H. LINK, Petersburg, Ind. 
IV. TIMIDITY AMONG COUNTRY DOCTORS. 



There is a great deal said about the 
timidity of the country doctor, and our 
city cousins often marvel at our hesitation 
and no doubt feel sorry for us without re- 
flecting on our environments or under- 
standing the conditions which either favor 
or hinder successful work. Among us 
there is no lack of boldness except when 
we lack exact information. We are far 
away from dissecting rooms, and our 
anatomy consists of what we learned while 
at school with what we can acquire by oc- 
casional references to Gray or some other 
text-book. We remember a great deal of 
theoretical teaching which blessed us in 
student days, and now and then recall a 
practical lesson which some one of our 
teachers gave, that serves to guide us 
through a doubt or difficulty. We are all- 
round specialists. To-day doing an ab- 
dominal section, to-night a high-forceps 
delivery or a podalic version, to-morrow 
amputating a toe, removing a pterygium, 
trephining for fracture, or pulling a tooth, 
then hurrying away to a case of typhoid 
fever or cholera infantum. Being well- 
grounded in the branches of medicine 
necessary to do all these varieties of work 
with credit to ourselves and satisfaction to 
our patients, we must, of necessity, be 
good in all lines and exact and thorough 
in none. Our obstetrics is better than 
that of the city surgeon's, but our surgery 
not so good. Our surgery is better than 
that of of our city friend who devotes him- 
self to obstetrics, but our treatment of the 
eye is not up with that of him who treats 



the eye alone. Our general practice in 
systemic diseases is not equal to that of 
Pepper or DaCosta, but we can reduce a 
dislocation or adjust a fracture better than 
either of them. There is a certain bold- 
ness, too, which prevails among hospital 
physicians and surgeons, because of the 
shortness of the time during which pro- 
fessional relations exist between them and 
their patients, and the lack of severe per- 
sonal responsibility which of necessity 
obtains among them. Of course the 
hospital physicians or surgeons are respon- 
sible to their conscience, and we believe 
they have as high a standard of rectitude 
as any set of men in the world ; but if a 
bad result follow their work, or they 
decide to try a new method or a new line 
of treatment, they do not have to explain 
to the friends of the patients and defend 
it from the harsh criticisms of envious 
rivals. 

We in country practice while losing 
a patient are always losing a personal 
friend, and not seldom alienating a whole 
family. This fact often makes us appear 
to hesitate where our friend of the hos- 
pital staff would cut the Gordian Knot 
with his scalpel and save a life, which, at 
the worst, would undergo no more risk 
from the operation than from the elf ects of 
the disease itself. The bread and butter 
argument creeps into our lives when we 
try to be most unselfish and we hesitate 
to take a course not backed by authority, 
because we get the moral support of our 
brethren, hence the support of public 



42 



Original Articles. 



Vol. lxviii 



opinion, only by treading the beaten path. 
The man in the city being more a law unto 
himself, and having charge of those who 
are looked after by the charity of others, 
is expected, occasionally, to strike out new 
roads for the benefit of mankind and for 
the purpose of settling doubts, or establish- 
ing methods or remedies that meet new 
demands'. The country doctor is to a 
large extent a slave to text-books. What 
exists between the leaves of conceded 
authorities is to him the garnered wisdom 
of ages; and the cautions and exceptions 
addressed to him by his well-thumbed 
authors, make as strong an impression as 
the rules and principles which they lay 
down for his general guidance. "It is the 
unexpected which always happens " say 
the French, and when one is in doubt it is 
the unexpected which he fears. Hence, 
text-books which ought to hold up his 
tired hands while the battle with disease 
or accident is being fought are but waver- 
ing supports, albeit the best in reach. He 
can not stray very far from the accepted 
teachings of his books, for in case of a bad 
result, neither expert, judge nor jury will 
sustain him. Medical journals and medi- 
cal societies can not lift him from the 
slough of text- book lore, because his 
county society meets very seldom, and the 
bad state of the roads, if no other reason, 
keeps him at home one-half the year. 
Journals may keep him alive to what is 
going on at the great medical centres, but 
the new ideas put forth in them must be 
tried many times by others ere he ven- 
tures to try them in his practice and upon 
his patients. 

The great names of the past are 
cherished by the country doctor with 
a reverence, which, if it did not carry 
with it too great a reverence alike 
for their teachings, might be commenda- 
ble. A man, however great, must often 
err, and thus it is that " The evil men do 
lives after them," even if the good be not 
all " interred with their bones!" 

The country doctor, in his daily work, 
never comes from under the shadow of his 
early teacher's influence. Of course, the 
exigencies of practice soon show him that 
they lack the infallibility with which his 
student imagination invested them. Yet 
their methods and precepts are remem- 
bered and often followed long after he has 
discovered that many of them were very 
ordinary men who had stepped into the 



place of teacher, not by reason of any in- 
herent quality of preeminent fitness for 
the place, but through some adventitious 
circumstance or attribute, foreign alike to 
professional character, and not necessarily 
coexistent with great professional attain- 
ments. As the faculties of none of our 
colleges contain more than two or three 
truly able teachers, it follows as a matter 
of course, that the vast majority of the 
teaching is done by a host of mediocres, 
who echo alike the errors and the truths 
of the past, mixing a great deal of what 
must be unlearned with what is known to 
be true, and tarnishing the brilliant things 
of others with the leaden hue of their own 
stunted minds. All this has a disastrous 
effect on those men who must go out to 
the world relying upon precepts from such 
a source for guidance. 

The modesty of the practitioner remote 
from medical centres adds to his timidity 
from other causes. Feeling his lack of 
exact knowledge, and greatly magnifying 
the advantage of his more favorably situ- 
ated brethren, he often gives nature a 
longer trial and a better chance than she 
would have in a city or larger town. This 
fact as often redounds to the benefit of 
the patient as a more active policy ; especi- 
ally, if that policy has no better reason 
behind it than enthusiastic boldness and 
strong self-confidence. If any one asserts 
his superiority, the country doctor not 
knowing how little, hotv very little differ- 
ence there is between the great lights in 
medicine and the more humble of its fol- 
lowers, rapidly concedes all that others 
claim for themselves; and, knowing that 
he cannot perform the wonders which 
others daily claim, takes it for granted 
that he can not be up to their standard, 
and blames his opportunities for much 
that is more fancied than real. He is 
ready at all times to confess his defects ; 
and, on account of them, he now and 
then withholds his hand, because he 
doubts its strength and skill. He per- 
forms his alloted tasks, feeling only that 
his conscience does not reprove him for not 
being as good on every line as some of his 
city friends are in some one particular 
field of work. 

The prevailing tone of both stereotyped 
and current medical literature has much 
to answer for in the matter of multi- 
plying the doubts and increasing the 
hesitation of the country physician. We 



January 14, 1893. Original Articles 



43 



are constantly warned at the threshold or 
end of the description or explanation of 
every operation or manipulation of magni- 
tude or difficulty, that only the specially 
trained or skillful should undertake it; 
that the skill to do most things is only 
vouchsafed to a few of the Lord's anointed, 
and that it is much safer to .call counsel 
than to undertake some delicate or danger- 
ous piece of work until we have become 
specialists. In other words, we must not 
go near the water until we have learned to 
swim. This makes a fine harvest for those 
who have learned to swim ; but it leaves 
us just where we began, standing on the 
bank shivering with dread at the water, 
while our patients drown before our eyes 
for want of that help which we ought to 
give. 

Another cause for our timidity and 
backwardness is the meager pay which we 
receive for our best and utmost efforts. 
To buy the best-books and to take the 
highest and best class of current literature 
costs money, while a liberal supply of 
necessary instruments is to the country 
doctor an expenditure of almost a small 
fortune. Being a representative of all the 
specialties and the practice of medicine 
also, to be moderately well equipped he 
must have a number of instruments for 
each line of work and the special instru- 
ments of diagnosis and treatment that 
pertain to successful practice in the mere 
application of remedies to the cure of dis- 
ease non-surgical in character. The city 
practitioner often gets more for the per- 
formance of one operation than the suc- 
cessful and skilled country doctor does for 
a year's work. As the gratitude of patients 
is in a direct ratio to the size of the fee 
paid, it can very readily be seen that there 
is small encouragement to anything like 
boldness in action or fullness and com- 
pleteness of equipment. 

Notwithstanding the truth of the fore- 
going, the history of medicine shows 
that the country doctor has at times 
risen to the level of the heroic, and, 
in the absence of sustaining counsel, 
by some bold act or sudden inspiration 
become an epoch-maker in the progress 
of a great and noble science. We 
remember with pride that the whole 
science of abdominal surgery owes its 
origin to the backwoods surgeon of Ken- 
tucky. We like to recall the fact that 
Baynham, another country doctor of Vir- 



ginia, operated successfully for ectopic 
pregnancy long before the advent of Law- 
son Tait. It was J. Marian Sims, a 
country doctor of the South, who put the 
operation of vesico-vaginal fistula on the 
list of curative lesions and who revolution- 
ised the whole practice of Gynecology. 

It was a country doctor in Ohio who 
first made the improved Cesarean section, 
sewing the uterine walls with silver wire, 
a procedure which, under the name of the 
Saenger operation, has led a great many to 
suppose that we owe it, like other good 
things, to Germany. It was Benjamin W. 
Dudley, another country surgeon, who 
made a lithotomy record so high that no 
man has ever yet been able to duplicate it, 
even though we have, by the aid of Ger- 
many, discovered a universal cause for all 
surgical failures — bugs. What a miser- 
able man this Dudley was who went on 
making one lithotomy after another, cur- 
ing his cases, while blissfully ignorant of 
the fact that everything he touched, even 
the very air he breathed, was literally 
swarming with bacteria or micrococci. Had 
he lived to the present time, he might, by 
the aid of chemical solution, have run his 
mortality up from four per cent, to ten or 
twenty per cent. In fact, by striving- 
hard, he might have equalled some of the 
best German operators in piling up a mor- 
tality list. 

Head Injuries with Aural Complications. 

Dr. J. E. Sheppard (Archives of Otol- 
ogy) says : 

1. That the division made by Dr. Buck 
of fractures of the temporal bone into (a) 
4 ' fracture or disastasis of the tympanic or 
squamous portion, in the region of the 
middle ear, without implication of the 
pars petrosa; and (jb) fracture of both the 
tympanic and petrous portions," is an en- 
tirely tenable and eminently practical one. 

2. That fractures of the temporal bone 
without fatal consequences, and even with- 
out loss of hearing, occur more frequently 
than is generally believed. 

3. That in all cases of suspected frac- 
ture of this part of the skull, a thorough 
examination (by speculum and reflected 
light) should be made of the external 
auditory canal, of the membrana tympani, 
and, so far as possible, of the tympanic 
cavity, as an aid to diagnosis and prog- 
nosis, and to obtain any indications that 
may exist for treatment. — Am. Lan. 



44 



Original Articles. 



Vol. lxviii 



CRIMINAL RESPONSIBILITY IN THE EARLY STAGES OF GENERAL 

PARALYSIS. 



FRANK P. NORBURY, M. D., Jacksonville, III. 



At no time in the history of civilization 
have influences so comprehensive and far- 
reaching been contributory to spurring 
men to action beyond their capacities to 
bear as to-day. We are " a restless nation 
possessed of an energy tempted to its 
largest uses by unsurpassed opportunities," 
the disastrous results of which are shown 
in premature decay, in that most prevalent 
disease, neurasthenia, with its attending 
miseries and in the increase of that form 
of mental derangement known as general 
paralysis of the insane. While it is true 
that syphilis is the basis of much of gen- 
eral paralysis, yet, the exciting cause, even 
in these cases, is over- work; brain tire and 
abuse of the nervous system. The 
American disease, neurasthenia, offers 
hope for recovery; the mental derange- 
ment, general paralysis, is a disease that 
carries its victims sooner or later, to the 
grave. A study of this most protean 
malady is of great importance to every 
physician, for its early recognition will 
often modify the progress of the disease 
anct prevent crime by placing the patient 
under proper treatment. 

Further, we are hopeful that with the 
advancement and dissemination of the 
clinical knowledge of this disease it will 
be recognized while in its functional stage 
and here arrested. Folsom, of Boston, 
has (of the American writers,) given us 
the most classical description of this dis- 
ease, which I hear quote. 

I. GENERAL PARALYSIS. 

" General paralysis is clinically a 
primary disease, sometimes acute, but for 
the most part subacute and chronic in its 
early manifestations, with a definite recog- 
nizable anatomical basis and progressive, 
in which symptoms of brain failure, too 
slight to be remarked at their actual in- 
cipiency, are rapidly or slowly succeeded 
by a cerebral inco-ordination, both psychic 
and motor, including under the term 
psychic the so-called moral as well as 
purely intellectual attributes of the mind; 
a disease which in its course involves every 
function of the brain and may in its vari- 
ous phases exhibit many of the symptoms 
observed by the neurologist, as well as most 
of those known to the alienist, first im- 



pairing, then paralyzing in its steady pro- 
gress all those high qualities, mental and 
physical, that distinguish civilized man; 
and finally, •after the wreck of mind and 
body destroying life itself." 

The early symptoms will concern us in 
this paper ; they have not been very satis- 
factorily studied, because the attending 
physicians have not distinguished general 
paralysis from other forms of insanity and 
as a consequence the prodromal stage is 
generally passed before the alienist meets 
the case. The family or friends have 
been aware of a change in the character 
and disposition of the patient, but have 
not been alarmed, "thinking it would 
pass away." 

But no! The case is progressive, and 
some day they realize that insanity exists 
and forthwith apply for hospital treatment, 
too late, however, for the benefit of the 
patient. Brush says it is unfortunate that 
the clinical features of the early symptoms 
of general paralysis are not more graphic- 
ally defined, and attributes the cause to 
the lack of observation on the part of the 
attending physicians, who in a very few 
instances have recognized the disease, 
even after it has advanced to such a degree 
as to require asylum care. 

The diagnosis of general paralysis is 
rarely made, as is evidenced in the follow- 
ing diagnosis taken from twenty-six cases 
coming under my observation during the 
past four years : Nervous prostration, mel- 
ancholia, traumatism, la grippe, brain 
softening, alcoholism, morphine habit. 
In the majority no form of insanity is 
given and the cause is stated as unknown. 

Folsom, of Boston, and Hughes, of St. 
Louis, have exhaustively studied the early 
symptoms of general paralysis. Folsom 
says the earliest signs of general paralysis 
are of the slightest possible brain failure. 
If, for instance, a strong, healthy man, in 
or near the prime of life, distinctly not of 
the nervous, neurotic or neurasthenic type, 
shows some loss of interest in his affairs or 
impaired faculty of attending to them ; if 
the become varyingly absent-minded, heed- 
less, indifferent, negligent, apathetic, in- 
considerate, and although able to follow 
his routine duties, his ability to take up 



January 14, 1893. Original Articles. 



45 



new work is, no matter how little, dimin- 
ished ; if he can less well command men- 
tal attention and concentration, concep- 
tion, perception, reflection and judgment; 
if there is no unwonted lack of the imita- 
tive, and if exertion causes unwonted men- 
tal and physicial fatigue; if the emotions 
are intensified and easily changed or 
excited readily from trifling causes ; if the 
sexual instinct is not reasonably controlled ; 
if the finer feelings are even slightly 
blunted ; if the person in question regards 
with a placid apathy his own acts of in- 
difference and irritability and their con- 
sequences, and especially if at times he 
sees himself in his true light and suddenly 
fails again to do so; if any symptoms of 
cerebral vasomotor disturbance are noticed, 
however vague or variable — then we can 
regard his case as one of general paralysis. 

Hughes, in a personal letter to me, says : 
" There is undoubtedly a pre-ataxic stage 
of general paralysis ; a hyperaemic condi- 
tion when the paretic individual engages 
in, or is inclined to engage in, business 
and other ventures having few features of 
certainty in outcome to commend them 
that would enlist the active financial in- 
terest of the person about to be afflicted 
with paretic dementia in his normal men- 
tal state. At this stage, when self-confi- 
dence is becoming supreme, and the mor- 
bid impression of conscious capacity for 
success in almost any undertaking is 
possessing and growing intenser in the 
mind every day, the victim of commenc- 
ing paresis may complicate his social rela- 
tions as he is liable to do his business 
affairs, and just as he might do and does 
do in beginning paresis, where the inital 
symptoms are those of mental depression 
or melancholia." 

Savage, of England, in a paper on the 
warnings of general paralysis, says : There 
are two forms of onset of the disease — the 
gradual and the sudden. In the latter, 
there is nothing to warn before the storm 
has broken. In the gradual onset there 
is a more or less regularly progressive de- 
generation of mind and body, so that the 
highest faculties show the first signs of 
change and the special attainments fail 
before the more general; the finer social 
and the finer muscular adaptations fail and 
changes and weaknesses in mind and body 
show themselves. To start with the motor 
side: Early fatigue is most marked, and is 
associated with indecision, doubt and 



hypochondriasis. Temporary aphasia he 
regards as an important symptom, and is 
present long before change in hand- 
writing is noticed. This change in hand- 
writing is specially an important symptom, 
and is present for a year or more before 
signs of general paralysis are declared. 
Facial expression changes, the face be- 
comes fat. The mental and moral tone is 
changed ; the changes of temper and char- 
acter are noticed early in general paralysis. 
Self-feeling is exaggerated, hypochondria- 
sis is a frequent warning, and in such cases 
the morbid ideas are centered in the 
gastro-intestinal tract. The combined 
motor and mental symptoms lead to a 
diagnosis of general paralysis. 

The symptoms, as detailed by these 
authorities, seem striking and capable of 
being recognized, but careful study of the 
patient and painstaking interrogation of 
the family and friends are also necessary 
to define a case of general paralysis. The 
mental symptoms are variable, but usually 
this feeling of well-being prevails, char- 
acterized by excessive cordiality, boasting 
of power and wealth, marked by extrava- 
gance in everything undertaken. Emotions 
are seemingly in a balance; anger is easily 
and hastily aroused and as easily «and 
hastily calmed; crying and laughing al- 
ternate quickly. Moral lapses are so fre- 
quent at this time that females are as- 
saulted, undue exposure of the person 
made in public places, sexual and alcoholic 
excesses are common, and so frequent are 
the varied moral lapses that the unfortu- 
nate subject, especially if he belong to the 
lower class of society, becomes lodged in 
jail for offenses committed. His irrita- 
bility and anger may lead him to murder, 
assaults, and trespass on the rights of 
others. His exalted ideas of power and 
authority cause consternation in assembly 
halls, churches and in the seats of govern- 
ment. Such, in brief, is an outline of 
the early symptoms of general paralysis ; 
the latter stages are seen within the walls 
of an insane hospital, where death, sooner 
or later, comes to relieve the weary suf- 
ferer of the burden of life. 

2. KESPONSIBILITY. 

Medicine and law differ radically on the 
question of responsibility. Scientific med- 
icine has been the pioneer to explore the 
still unsettled regions of criminality among 
the insane, and has satisfactorily estab- 



46 



Original Articles. 



Vol. lxviii 



lished principles which the legal profes- 
sion must sooner or later acknowledge as 
scientific truths. This question of re- 
sponsibility, as viewed by medicine and 
law is, as Judge Somerville, President of 
the New York Medico-Legal Society, says, 
' ' the same old fight of science against the 
crystallized prejudices of error and ignor- 
ance." 

The law, on the other side, claiming cul- 
pability when knowledge of right and 
wrong exists; medicine, on the other, 
holding there is no criminal act when the 
individual cannot choose between right and 
wrong because of the destruction of the 
power of self-control. The medical test 
is based on the presence of disease and its 
abnormal results on conduct; the legal 
test is metaphysical and theoretical. Med- 
ical diagnosis is based on pathology and 
experience ; the legal ignores any physical 
condition which does not affect the moral 
attributes. The law cares nothing for im- 
pulse, loss of will power or sudden change 
of character and conduct without motives 
or from childish incentives. Medicine 
tests scientifically by taking in the whole 
man ; it gives a study of the individual, a 
comparison of his mental condition when 
the trime was committed, with himself at 
periods remote and subsequent. By so do- 
ing we permit of the only rational method 
of determining sanity from insanity. 
" ' We supplant tradition and fiat of stat- 
utes by the facts of clinical medicine from 
which we draw just conclusions." We at 
once recognize the importance of a study 
of mental diseases in order to thoroughly 
and adequately determine responsibility. 

A physician is, by right, the proper per- 
son to conduct an examination to deter- 
mine the unsoundness of mind. The famil- 
iarity with mental diseases accorded him 
in our State by the law, requires him to 
acquaint himself with these diseases in 
order to sustain this position. That he 
does not do this we are painfully aware, 
and because of this inattention, either 
through ignorance or indifference, the 
medical profession has been made to suffer 
ridicule and opprobrium from lawyers, 
judges and the press. So far has this 
gone, that it has been said that any ordi- 
nary man is able to detect any form of in- 
sanity as well as a physician. 

We, in the description of general paraly- 
sis, have shown the difficulty attending the 
diagnosis of this form of insanity and have 



insisted upon prolonged observation in 
order that no mistake may be made. The 
same will apply to all forms of insanity, 
especially so in cases involving criminal 
responsibility, and we reiterate that, for 
the sake of justice in cases presenting the 
plea of insanity, where doubt exists as to 
insanity, observations of the case be made, 
and preferably by temporary commitment 
to an insane hospital, where the experienced 
superintendent and other medical officers 
may scientifically examine the case. The 
want of such methodical observation has 
no doubt caused many innocent to suffer 
and many guilty to escape. Such an ex- 
amination impartially pursued will render 
great assistance to the courts and aid in 
the establishment of medical expertism 
upon a firm and scientific basis. 

3. RESPONSIBILITY IN ITS BEARING UPON 
GENERAL PARALYSIS. 

I am sure there are many unfortunates 
serving sentence to-day for crimes com- 
mitted, who should be treated as sick pa- 
tients and given the attention they de- 
serve. An analysis of their crimes will 
show that a diseased mind prompted the 
act and a disorganized will power per- 
mitted its commission. The crimes, if 
they should so be called, of a general 
paralytic differ from those of the normal 
or criminal insane. Bevan Lewis says 
regarding the crimes of a general paralytic 
as compared to the moral insane : "In the 
latter the crimes indicate impulsive and 
uncontrollable states as the result of a 
lowered or defective moral sense; the nor- 
mal inhibitory control is wanting and 
instinctive impulses rise in full activity. 
It is not so with the acts of a general 
paralytic ; they are neither premeditated 
nor impulsive, but casual, often appearing 
to be unconsciously performed; even if 
the act appear determinate its nature and 
consequences are wholly obscure to the 
agent's mind." 

And here the essential nature of these 
acts on the part of each subject becomes 
apparent; the high degree of representa- 
tiveness essential for the recall of similar 
actions previously performed and the 
vivid realization of the consequences of 
such action in the past, is here wholly 
wantingless; and still less is that re-repre- 
sentative faculty intact, which enables 
him to contrast the act as viewed in its 
nature with certain ethical canons. The 



January 14, 1893. Original Articles. 



47 



moral lapse is therefore truly significant 
of a clouded intellect, an act of theft may be 
committed with open effrontery, no at- 
tempt at concealment being made ; the most 
wanton outrage on public decency, the most 
audacious libertinism, may be committed 
quite oblivious to being a breach of public 
morals. Hughes, in his letter, says: "I 
would suspect and recommend surveillance 
for a very active business man of from 36 
to 45 years of age who might be found 
acting in a manner different from that 
which, up to that time was natural to him 
in business or social affairs, especially if 
his conduct was such as might be attri- 
buted to a man under the exhilaration of 
drink, when it could be clearly shown 
that the man did not indulge in alcoholic 
drink at all. I am convinced that a good 
deal of unrecognized and irreparable harm 
has been done to the interests of paretics 
and the welfare of the families by rash 
procedures on the part of the former, 
which were unnatural to them in their 
thoroughly sane condition by acts (busi- 
ness or otherwise) committed in the 
hypersemic preataxic stages of this dis- 
ease." 

Folsom, in a recent letter to me, says, 
regarding the conviction and imprisonment 
of general paralytics : 

" I do not see how it is consistent with 
a reasonable sense of justice to convict a 
general paralytic in any stage of his dis- 
ease, no matter how early, and when a 
man of previous good character commits a 
crime it seems to me that he should be 
placed in an insane asylum for observation, 
if there is any doubt as to his responsibil- 
ity. I have no doubt that in the near fu- 
ture all of our states will have laws, as 
some of them now have, empowering 
judges to send people to insane asylums 
for observation in case of doubt of their 
sanity, and that judges will more fre- 
quently use this power." 

In our State we have no such provision ; in 
fact, our lunacy law is a failure, both to 
the practical commitment of the insane 
and the protection of their best interests. 
The mittimus on which an insane person 
who has committed a criminal act is ad- 
mitted into the insane hospitals of this 
State is equal to a life sentence in cases of 
general paralysis. It instructs the super- 
intendent of an insane hospital ' ' to take 
the body of said defendant (the hopeless 
paralytic) and confine him in said hospital 



until he has fully and permanently recov- 
ered from his insanity," — which is when 
he dies. The general paralytic is not 
justly committed to a hospital on such a 
legal paper, because, first, he is a sick 
man ; second, he is not responsible for any 
criminal act whatever, and, third, it is of- 
tentimes to his advantage and a pleasure 
to his friends to have temporary absence 
from the hospital, and in case of impend- 
ing death, to satisfy the desire of his 
family or friends, it may be best to remove 
him to his home, which cannot be done 
when committed on a mittimus. 

My conclusions are, after carefully 
studying the medico-legal bearings of re- 
sponsibility in the early stages of general 
paralysis : 

I. General paralysis is a plea for irre- 
sponsibility. 

II. No judge is warranted in commit- 
ting a general paralytic to the peniten- 
tiary. 

III. It is not judicious or right to 
commit general paralytics to insane hospi- 
tals on a mittimus. 

IV. When in doubt as to the existence 
of general paralysis it is the duty of the 
judge or jury to forego sentence #nd 
commit the individual to an insane hos- 
pital for observation, at least long enough 
to determine the existence or non-existence 
of general paralysis. 

LITERATURE. 

C. F. Folsom — Transactions Association Medical 
Superintendents Institutions for Insane, 1890. Trans- 
actions American Association of Physicians, 1890. 

Judge Somerville — New York Medico-Legal Jour- 
nal, 1889. 

Clark Bell — New York Medico-Legal Journal, 
1890. 

Bevan Lewis — Mental Diseases, 1890. 
J. Hume Williams — Wood's Monographs, Vol. XII. 
E. F. Brush — Annual Medical Sciences, 1890. 
George Savage — Annual Medical Sciences, 1891. 
A. Wood Benton — New York Medico-Legal Journal, 
1889. 



Collector — Mr. Trager, will you sub- 
scribe toward the decoration of the soldiers' 
graves? Mr. Trager — No, sir! The men 
whose graves I want to decorate ain't dead 
yet. 

Poor, Dear Man ! — Mrs. Grogan — An' st 
't the 'roomatics thot's ailin' Hogan? Mrs. 
Hogan — No. He shpraint his back lasht 
ivenin' tryin' t' t'row me out tb' windy ; 
poor, dear man ! 



48 



Clinical Lectures. 



Vol. lxviii 



CLINICAL LECTURES 



INFLAMMATION; PUS; POSITIVELY AND NEGATIVELY CHEMO- 

LAOTIO SUBSTANCES. 



HENRY W. CATTBLL, A. M., M. D.* 



Inflammation is a composite patholog- 
ical process, and is the most important 
process with which we have to deal in the 
whole subject of gross morbid anatomy. 
There is hardly a process which starts or 
ends a pathological change that has not 
inflammation as a factor at some time or 
other in its course. A clear conception 
of this subject of inflammation, added to 
a full knowledge of the anatomy of the part, 
together with a good understanding of such 
conditions as infiltration and degeneration 
will lead you to comprehend most clearly 
all special pathological changes. 

Changes due to irritation of the con- 
nective tissue, is a brief but unsatisfac- 
tory definition of inflammation. The 
usual definition is a much longer one, and 
is either a resume of the process or a 
description of the clinical symptoms. 
According to Ashurst, you must consider 
clinically the causes, symptoms, course, 
termination, treatment, and pathologi- 
cally, the phenomena of function, nutri- 
tion, formation and destruction. 

We have first in inflammation an in- 
creased action, though this may last but 
for a very short time. We may have for 
example, an increased function in the 
part, which is able to accomplish more 
than it did before. Now, this increased 
functional activity may only last for a 
short time, say half an-hour, or even 
shorter.- Then we shall have a lowering 
of function, and in case the process is 
continued we may have a total abolition 
of function. This is also true in regard 
to nutrition. Then as to the destruction : 
here we have two terminations, one 
sloughing or gangrene, the other ulcera- 
tion. In the first form, sloughing or 
gangrene, we have the macroscopical ap- 
pearances; in the second, ulceration — a 
molecular removal of the microscopical. 

The sources of inflammation are two- 
fold: first, diseased or dead cells; and 
second, micro-organisms. In the first 
case a cell, from some cause or other, dies 
within the body and as a result it becomes 

^Demonstrator of Gross Morbid Anatomy at the Un- 
iversity of Pennsylvania. 



an irritant and we may have all the signs 
of inflammation set up. The second con- 
dition is that which is due to micro-organ- 
isms, and is the one which is now being 
chiefly studied. In fact, it is difficult to 
conceive of an inflammation which has 
never been affected by micro-organisms. 
Therefore, the usual cause is considered a 
combination of the dead cells and the mi- 
cro-organisms. 

This constitutes the clinical form, which 
is described in works on surgery, and 
which is the variety that you will be 
called upon to treat. 

As to clinical features of inflammation, 
pain, swelling, heat and redness — the 
pain is due to the fact that the exudate 
presses upon the terminal ends of the per- 
ipheral sensory nerves ; the redness is due 
to the increased blood supply to a part, 
with a diapedesis of the red blood corpus- 
cles ; the swelling occurs because there is 
more fluid in the part, containing leucocy- 
tes, micro-organisms and their products, 
connective tissue cells, etc. The cause of 
the heat is a debated question ; it is uncer- 
tain whether it is due to the fact that the 
arterial blood is there in larger quantity, 
or whether there is an increased chemical 
and mechanical change taking place in the 
part, or whether we have increased heat 
dissipation. There have been thousands 
of experiments made to ascertain the cause 
of this, but these experiments seem fre- 
quently to contradict each other. Where 
there are so many theories one may be 
quite sure that a combination best explains 
the fact. 

We have in inflammation a substance 
known as pus. This has been described 
in the older surgeries by various names 
which it is necessary for you to under- 
stand. The old idea of a laudable pus is 
that pus which is of a greenish hue, with 
not a bad odor, and which occurs in those 
cases which are apt to recover. Therefore, 
it is a healthy pus. Sanious pus is that 
form in which blood and pus are mixed in 
varying proportions, from the slightest 
tinge to that in which it is mostly blood. 
Then we have the ichorous pus — which is 



January 14, 1893. 



Clinical Lectures. 



49 



thin and acrid. We have also the muco- 
pus and the sero-pus in which we have 
mucous or serum mixed with the pus. 

Now, what is pus ? Chemically, pus 
may be described as an albuminous fluid 
of a specific gravity varying from 1021 to 
1042, containing the peculiar constituents 
of the tissue, whether they be cells, salts or 
organic substances with a mixture of leu- 
cocytes, micro-organisms and certain 
chemical bi-products, such as peptones, 
proteid compounds and leucin. If you 
open an acute abscess and examine under 
the microscope the pus, magnified about 
450 times, you will find a great number of 
leucocytes, and these leucocytes will be 
practically of one size. There will be a 
very few cells larger than the leucocytes, 
which are connective tissue cells. If you 
will examine closely you will find that 
these leucocytes possess amoeboid move- 
ment. You will sometimes be able, 
especially on a warm day, to examine them 
very easily. If acetic acid be added to 
the pus, we shall have a clearing up of the 
protoplasm and the appearance of a num- 
ber of nuclei, showing that at some time 
or other in the life history of the cell 
there had been an attempt at multiplica- 
tion. When the pus is first being pro- 
duced we have a number of micro-organ- 
isms present ; but after a time the micro- 
organisms become rarer and you should 
not be disappointed in opening a large 
abscess if you are not able to find any 
micro-organisms at all. You expect to 
find it loaded with various micro-organ- 
isms. But the micro-organisms have died, 
have undergone some form of necrosis and 
have been carried off. This is well illus- 
trated in tuberculosis. You might not 
find the tubercle bacilli in the cheesy 
glands of the neck, even though you 
should stain for them most carefully. 
How will you therefore demonstrate their 
presence ? By taking some of the cheesy 
material and injecting it into a guinea pig 
— an animal which is especially susceptible 
to inoculation by tubercular material — and 
allow the bacillus to develope tuberculosis 
in the animal. 

What micro-organisms are most fre- 
quent in the formation of pus ? Many 
have been described. The list is a very 
long one and is steadily increasing. The 
way to remember them is simply to note 
that the names of such micro-organisms 
usually have the prefix pyo, which means 



pus; frequently pyogenes-pus-producing. 
They are also described in accordance with 
their color, citreus, albus, aureus, etc. ; 
and by their shape streptococcus, cocci in 
chains; staphylococcus, cocci in bunches 
like grapes, etc. But not all micro-or- 
ganisms that are thus capable of produc- 
ing pus have the prefix pyo. The bacilli 
of glanders and tuberculosis are cases in 
point. 

The cholera bacillus does not produce 
pus. This is important, as the anti-vac- 
cine of Haffkine is capable of being intro- 
duced into man without fear of producing 
an abscess; only an indurated nodule is 
sometimes left at the seat of inoculation. 

What are leucocytes for? This is a 
question that has been specially studied of 
late. When a micro-organism gains ac- 
cess to a part, has it the property of at- 
tacking the leucocytes, or have the leuco- 
cytes the power of attacking the micro- 
organisms ? Do we know that the micro- 
organism has the property of eating up 
the leucocyte which has become granular 
or has undergone fatty degeneration ? It 
is no uncommon thing to see five, six or 
seven micro-organisms inside of a pus cell. 
Now, did the pus cell swallow up the 
micro-organism, or did the micro-organ- 
ism go into the pus cell in order that it 
might have food ? That is the question. 
However that may be, the fact is, that 
when the leucocyte attacks the micro-or- 
ganism (or the micro-organism attacks the 
leucocyte) we have certain poisonous pro- 
ducts, which are in themselves capable of 
destroying the micro-organism which pro- 
duced them. This is an important point. 
You know that in fermentation if the al- 
cohol reaches twenty-five per cent, the fer- 
mentation ceases. So it is here. If the 
micro-organism has had an opportunity to 
grow, it produces a poison which is de- 
structive to producer. Pathologists are 
now endeavoring to isolate such chemical 
substances from the 'micro-organisms with 
intent to confer immunity to disease by in- 
oculation. 



For a scald or burn there is nothing su- 
perior to wet bicarbonate of soda applied 
to the part. 

According to Dr. Miles there is an 
abortive form of typhoid fever. These 
attacks usually last from nine to twelve 
days. 



50 



Communications , 



Vol. lxviii 



COMMUNICATIONS. 

THE CUEETTE IN OBSTETEIC AND GYNECOLOGICAL PEA.CTICE. 

JNO. G. CECIL, M. D., Louisville, Ky. 



The curette, like many other surgical 
instruments, has experienced seasons of 
favor and disfavor. At no time, however, 
as at the present, has its usefulness been 
so fully recognized. So much have the 
dangers attending the use of the instru- 
ment been magnified, that unquestionably 
there yet lingers in the minds of many, 
strong prejudices against it. 

Many, in fact most of the objections 
that justly obtained before the application 
of aseptic precautions, are now no longer 
tenable. It can never be maintained that 
the use of the curette is entirely devoid. of 
danger, but hedged about with all the 
modern methods of preventing septic in- 
fection, it may be stoutly claimed that 
the danger is reduced to a minimum in any 
case of whatever kind, where its use is 
called for. So, in any case, where the in- 
dications are plain, the most cautious and 
timid need scarcely hesitate in its applica- 
tion. It is hardly necessary to add that 
the use of this instrument, in the hands of 
a bungler, or careless manipulator, is capa- 
ble of doing incalculable harm, despite 
aseptic precautions let them be ever so 
thoroughly instituted. 

The good results that may be had are so 
manifold and great, and so far outweigh 
the dangers, that to enter a plea for a 
place for it in the armamentarium of the 
obstetrician or gynecologist, would be a 
work of supererogation. 

When I say curette I do not confine my 
meaning to those bent wire affairs which 
have all along been regarded as harmless, 
and we might safely add, almost useless, 
at least in gynecological practice, but to 
the modern improved instruments with 
cutting edges. 

The indications for the use of a dull or 
a sharp curette, depend upon the exigen- 
cies of each case, and must be left largely 
to the judgment of the operator. There 
is no doubt that much of the disfavor the 
curette has fallen into is due to the use of 
a dull instrument, where a sharp one was 
demanded. 

Before referring to the special indica- 
tions for the use of the curette, and this 
part of my subject alone would lengthen 



this paper beyond its intended limits, a 
brief consideration of the preparations and 
methods necessary to its proper and safe 
use, will not be inappropriate. 

To begin with, curettage should be dig- 
nified by the name of an operation and the 
antecedent preparations should be just as 
jealously carried out as those, for instance, 
for an abdominal section. Many untoward 
results have followed because the operator 
deemed it only necessary to place the 
patient in position, introduce an instru- 
ment, itself probably not clean, and scrape 
away some foreign body, or adventitious 
growth. 

Concerning the technique of curettage, 
I cannot do better than follow the sug- 
gestions of that most zealous advocate 
of the procedure, S. Pozzi, in his 
recent superb work on gynecology. The 
patient should have a full bath the even- 
ing or the morning of the operation. The 
rectum emptied by enema, the bladder by 
catheter, the external genitals thoroughly 
washed with soap and water, and afterward 
with a strong antiseptic solution; vaginal 
injections of sublimate solution 1 to 2000 
should be enjoined twice daily for several 
days prior to the operation. On the day 
of the operation three injections are to be 
given, the first two at intervals of an hour, 
the third at the very moment of the oper- 
ation. It must be borne in mind that if 
bichloride of mercury is used for douch- 
ings, that gynecological patients will 
safely stand stronger solutions than ob- 
stetric cases. Should the cavity of the 
uterus need powerful disinfection, (as in 
certain cases of gangrenous fibromata?, in- 
trauterine cancer with putrid fungosities, 
etc.) it is advisable to extend the douch- 
ings into the cavity. There may exist a 
demand for continuous irrigation, if so it 
is readily applied by means of the irri- 
gating curettes or other devices. Though 
pain in many cases is not great, yet for 
the sake of thoroughness and control of 
the patient, an anaesthetic is demanded. 

The operation may be satisfactorily done 
in either the dorsal or lateral decubitus. 
The vaginal walls are separated and held 
apart by retractors or a suitable speculm 



January l-L, 1898. Communications. 



51 



in the hands of assistants. The first step 
of the operation is to fix the n terns with 
tenacnla or Mnsenx forceps. The cervical 
canal must be sufficiently dilated to per- 
mit the easy passage of the curette. This 
is safely and quickly accomplished by the 
graduated or the steel dilators. The 
choice of the curette is, as has already been 
hinted at, not a matter of indifference. 
In general terms it may be said that dull 
instruments are most suitable and safest 
for obstetric cases, while the sharp or cut- 
ting instruments are most serviceable in 
gynecological cases. The scraping of the 
cavity of the womb should be done in a 
systematic manner. Beginning at a cer- 
tain point, say the posterior wall, every 
part of the surface should be carefully 
gone over until the starting point has been 
reached. During the progress of the scrap- 
ing, if it is necessary from time to time to 
remove the detritus, this can be done by 
the spoon-shaped instruments, or by the 
irrigating tube. If it is desired the field 
of operation can be entirely submerged 
throughout the operation by an antiseptic 
solution, by simply elevating the hips of 
the patient and filling the vagina with the 
fluid. When satisfied that every part of 
the cavity has been curetted, it should be 
thoroughly irrigated with a hot antiseptic 
solution, this followed by application of 
some mild caustic or packed with a strip 
of iodoform gauze. The patient should 
be kept in bed for three or four days at 
least, even in the simplest cases. Though 
to emphasize the safety of this operation 
under antiseptic management, I have seen 
surprisingly good results follow the use of 
the curette in gynecological cases, with 
no bad effects whatever, that were operated 
upon in the University outdoor clinic, 
that were allowed to go some distance to 
their homes, and where it is certain in- 
junctions to remain in bed were not fol- 
lowed. It has been extremely gratifying 
both to Prof. Anderson, with whom I have 
been associated, and myself, that not one 
unfortunate complication has followed 
this method of treatment, in the many 
cases that have been subjected to it, even 
with the rather incomplete antiseptic pos- 
sibilities of an outdoor clinic. But, even 
with so good a record to substantiate the 
foregoing, similar risks are not advised, 
only mentioned to demonstrate the possi- 
bilities of this treatment. 

The special indications are so numerous 



that even brief mention of them in this 
connection, will not be permissible. In 
obstetric practice, there are two conditions 
that demand a curette, and demonstrate 
its usefulness most plainly; they are 
persistent hemorrhage, due to retained 
secundines or fungous degenerations of 
the endometrium after labor or abortion ; 
and the septic conditions of the puer- 
peral patient. It is in this class of cases 
that the dulled curette finds its greatest 
field of usefulness, and yields the most 
brilliant and satisfactory results. Partic- 
ularly in those annoying hemorrhages that 
follow incomplete abortions, does the 
curette answer the demand. Instead of 
temporizing with ergot, hot douches, or 
other hemostatics, the curette is the cer- 
tain, safe, and rapid substitute. Much 
time and annoyance is saved, and the 
subsequent progress of the case is most 
gratifying. In the management of septic 
conditions that follow labor, either pre- 
mature or at full term, I am disposed to 
claim for the curette an important place. 
Any one who has made even a macroscop- 
ical post-mortem observation of the endo- 
metrium of a case of puerperal septicemia 
can see at a glance the indication for the 
curette. Here is a cavity, the lining 
membrane of which is a decomposing 
mass. The most important part of the 
management of such a case is to cleanse 
this cavity and afterward keep it clean. 
1 do not advocate inconsiderate invasion 
of the puerperal womb, on the contrary, 
unless the indications are plain, am much 
opposed to it. I am satisfied that many 
cases, especially in private practice, are 
lost, because we are either too slow, or 
else lack courage to apply remedial meas- 
ures that give us the best, and often, the 
only hope. I refer especially to the intra- 
uterine douches and the curette, and it 
should have a fair trial, even to the extent 
of continuous irrigation. If the contin- 
uous irrigation fails, recourse to the 
curette is the dernier resort. The curett- 
ing will not reach poison that has already 
been taken up by the lymphatics or blood- 
vessels, but it will limit the further pro- 
duction of it. With the curette the 
sloughing surface is bodily removed, and 
with it the focus of infection; in fact, we 
are treating this as we do any sloughing 
surface in surgical cases. It will be seen 
at a glance that this procedure should not 
be deferred too long, if we would reap the 



52 



Communications. 



Vol. lxyiii 



benefit. Many cases, apparently hopeless, 
may be saved by this active and radical 
measure. 

The limits proposed for this paper will 
forbid extended account of the applica- 
tion of the curette to many of the partic- 
ular cases of gynecological character, or 
to detailed description other than what 
has previously been mentioned, of the 
method of using it. 

In those obstinate cases of so-called 
"uterine or cervical catarrh" that be- 
come such an annoyance to the busy prac- 
titioner — and such a godsend to the poor 
but aspiring young gynecologist — because 
they are not inclined to get well, of all 
the curative procedures that are lauded by 
their respective authors, none promise so 
well as a vigorous attack with a sharp 
curette. My own experience with the 
curette in this class of cases has been uni- 
formly satisfactory. The cutting must be 
deep enough to remove the diseased folli- 
cles to their entire depth, and when this 
is done, certain relief will seldom fail. 

Painful and intractible cases of mem- 
braneous dysmenorrhoea can be most effec- 
tively treated and cured by judicious 
use of the sharp curette. The operation 
should be performed just prior to men- 
struation. 

The small sized sub-mucous fibroid 
tumors that cause excessive and dangerous 
hemorrhage, can be brought under the 
benign influence of the curette with sig- 
nal advantage. The hemorrhage in these 
cases is not so much from the tumor as 
from the uterine mucosa, which is kept in 
a constant state of congestion and irrita- 
tion by the presence of the fibroid. 

Much can be said of the value of the 
curette in the management of cases of 
uterine cancer that are beyond the reach 
of the more radical operations. The 
unfortunate patient can be made more 
comfortable to herself, her friends, and 
attendants; the rapid progress of the 
destructive process may be in a measure 
stayed; septic infection can, for a time, 
at least, be warded off, and alarming hem- 
orrhages can sometimes be anticipated 
and put under more perfect control. The 
scrapings of the curette can be utilized for 
diagnostic purposes when cancers are sus- 
pected in the body or fundus of the 
womb. 

Enough has been said to fully demon- 
strate the usefulness of this instrument in 



the gynecological field. While much 
may be said of the indications for the 
curette, much has also been said as to the 
contra-indications, perhaps too much. 
Many modern authorities seem disposed 
to ignore such contra-indications as have 
become classic, namely, acute inflammation 
in and about the uterus and its appen- 
dages, and, also, chronic inflammations in 
the same regions that have left the womb 
fixed by many adhesions, and which seem 
disposed to rekindle upon slight provo- 
cation. 

I cannot yet bring myself to the point 
of advocating the bold use of this instru- 
ment in the presence of such conditions, 
when the results may be so dire and 
regrettable. 

The Remedial Use of Apples. 

Chemically the apple is composed of 
vegetable fibra, albumen, sugar, gum 
chlorophyl, malic acid, gallic acid, lime 
and much water. Furthermore the Ger- 
man analysts say that the apple contains a 
larger percentage of phosphorus than any 
other fruit or vegetable. The phosphorus 
is admirably adapted for renewing the es- 
sential nervous matter, lecithin of the 
brain, and spinal cord. It is, perhaps, 
for the same reason, rudely understood 
that old Scandinavian traditions represent 
the apple as the food of the gods, who 
when they felt themselves to be growing- 
feeble and infirm, resorted to this fruit re- 
newing their powers of mind and body. 
Also, the acids of the apple are of signal 
use for men of sedentary habits, whose 
livers are sluggish in action, those acids 
serving to eliminate from the body noxious 
matters, which, if retained would make 
the brain heavy and dull, or bring about 
jaundice or skin eruptions and other allied 
troubles. 

Some such an experience must have led 
to our custom of taking apple sauce with 
roast pork, rich goose, and like dishes. 
The malic acid of ripe apples, either raw 
or cooked, will neutralize any excess of 
chalky matter engendered by eating too 
much meat. It is also the fact that such 
rich fruits as the apple, the pear and the 
plum, when taken ripe and without sugar, 
diminish acidity in the stomach, rather 
than provoke it. Their vegetable sauces 
and juices are converted into alkaline car- 
bonates, which tend to counteract acidity. 
— A 7 ". Amer. Prac. 



January 14, 1893. Society Reports. 



53 



SOCIETY REPORTS. 

THE SUEGIOAL SOCIETY OF LOUISVILLE. 

Stated Meeting of October 10, 1892. 



Dr. Jno. G. Cecil, Vice President, in 
the chair. 

FRACTURE OF THE PATELLA. 

Dr. W. C. Dugan: I simply present 
this patient to show the result of an opera- 
tion for fracture of the patella. It is a 
little early yet to tell definitely what the 
result is going to be, but there seems 
to be a good bony union, and I believe he 
will have perfect motion in the joint. 
Eighteen weeks ago a wagon ran into this 
man and mashed his patella. I saw 
him a short time afterward and the frag- 
ments were separated at least three and one- 
half inches ; it was a transverse f racture, 
with two or three fragments broken en- 
tirely out. The operation was done one 
week afterward, the fragment united by 
silkworm gut. You will observe two or 
three fistulas still open. 

One word concerning the anatomy of 
the muscles of the patella. It is usually 
stated in our books that the quadratus 
extensor, or the triceps extensor, is inserted 
into the patella. This is clearly a mistake. 
By careful dissection the muscles can be 
removed leaving the patella attached to 
the ligaments and serous capsule of the 
joint showing that the muscles are not in 
reality attached. In the case above re- 
ported there was great distension of the 
joint at time of operation, and he had 
much pain from this distension. He has 
suffered little or no pain since being oper- 
ated upon. I went to see this case with- 
out my bone drill, and holes were made 
in the bone with a pair of barber's scis- 
sors. He has not had an untoward symp- 
tom, and I believe will make an unevent- 
ful recovery. I am decidedly in favor of 
the open method of treating these cases, 
when there is much separation. If the 
fragments are in good position, that is 
when the muscular aponeurosis is not 
torn, I do not consider it advisable. 

DISCUSSION. 

Dr. A. M. Vance: I have never per- 
formed the operation of suturing the 
patella, but have assisted in several opera- 
tions of the kind. I doubt very much if a 
bony union can be obtained in fracture of 



the patella without the operation advocated 
by Dr. Dugan; still, I must say that very 
firm and unyielding union can be obtained 
by proper mechanical means, if treat- 
ment is continued a sufficient length of 
time. I have several cases where a func- 
tionally perfect limb resulted ; in fact, have 
never failed to get a very useful limb after 
this injury. 

REMOVAL OF APPENDIX, DEATH FROM 
URAEMIA. 

Dr. Jas. Chenoweth : I have a speci- 
men that I would like to show : It is an ap- 
pendix vermiformis removed two weeks ago 
last Friday, from a man thirty-one years of 
age, a farmer, who had always been in good 
health, and a strong, athletic looking sub- 
ject. I saw him about a year and a-half ago 
with a slight attack of catarrhal appendi- 
citis, little or no fever and not much pain. 
He stated to me then that he had two 
similar attacks two or three years before ; 
he recovered from this attack and I heard 
nothing more of him until two weeks ago 
last Friday. That morning he came to 
town from the country,feeling a little sick; 
did not eat any breakfast; suffering some 
pain in the right side. I saw him two 
hours afterward ; he had gotten verv much 
worse ; suffering intense pain ; cold, clammy 
perspiration ; suffering a great deal from 
shock ; pulse 60 when normal, was then 82 ; 
temperature 99.5° F. ; abdomen slightly 
tympanitic even at that time. I thought 
he probably had perforation of the 
appendix, or it was on the verge of per- 
foration, and had him sent to the Infirm- 
ary, advising immediate operation. Two 
hours after reaching the Infirmary pulse was 
106, temperature 101° F., and still suffering 
intense pain; abdomen more distended; 
very tender, could hardly touch him at 
all on the right side. I operated upon 
him at two o'clock, seven hours after the 
attack came on. I found the intestines 
greatly distended and very much reddened, 
showing evidences of peritonitis. The 
colon protruded as soon as the abdomen 
was opened ; by following the colon down, 
without much difficulty I found the ap- 
pendix low down in the pelvis, slightly at- 



54 



Society Reports. 



Vol. lxviii 



tached to the wall, not very firm and 
easily detached; it was brought up and 
found to be about the size of a finger, and 
three or four inches long. It had to be 
handled carefully to prevent rupture; it 
had not perforated but was very much 
distended, and evidently on the verge of 
perforation. The appendix when re- 
moved contained two small fecal concre- 
tions. The patient was on the table about 
twelve minutes ; pulse at the time about 
60. He was very much nauseated, and 
vomited severely after the operation ; no 
acdon of the bowels, and still considerable 
distension. By repeated enemata his 
bowels were started, the nausea subsided, 
and he seemed to be doing very well. The 
first night after operation temperature 
was 102° F. but as soon as his bowels 
commenced to act, temperature went down 
to normal, running from 98.5° to 99° F. 
The stitches were removed on the eighth 
day and union had taken place. On the 
ninth day there was a little discharge 
from the lower stitch, where some fluid 
collected between the peritoneum and 
muscles; temperature on the tenth day 
went up to 101° F. ; I made an examina- 
tion and found a little discharge collected 
through the night ; there was no inflam- 
mation of the skin and no tenderness in 
the right side ; never had any pain after 
the operation. I opened the lower part of 
the wound and found a little cavity filled 
with fluid; the peritoneum had united 
perfectly, leaving no tenderness and no 
induration. On the morning of the four- 
teenth day temperature (which had gone 
down after cleaning out this little ac- 
cumulation to 99° F.,) went up to 101° F. ; 
he seemed rather restless and nervous, but 
talked in a perfectly rational manner and 
felt quite well. About two hours after- 
ward I had a telephone message to come 
to the Infirmary as the man was uncon- 
scious. I went out immediately, found 
the patient in a comatose condition, gave 
him a hypodermatic injection of whiskey; 
pulse about 150. He never fully gained 
consciousness and died about 8.30 that 
night. He had been passing water in the 
natural way, and there was no occasion 
for using the catheter, but on my last 
visit to the Infirmary I introduced the 
catheter, and drew off some urine, found 
it loaded with albumen, death being due 
evidently to uraemia. 



DISCUSSION. 

De. E. R. Palmer: Did you make a 
post-mortem, and were the kidneys ever 
examined? 

Dr. Jas. Chehweth: No post-mor- 
tem was made, and the kidneys were not 
examined. 

Dr. W. O. Dugan: Do you think the 
nephritis was caused by the anaesthetic? 
1 have seen several cases of suppression 
following operation, but they came on 
within the first twenty-four hours, and 
every- one after chloroform anaesthesia. 

Dr. Jas. Chenoweth: 1 believe the 
man had nephritis before the operation. 
He became very much cyanosed when tak- 
ing chloroform. While he had never been 
sick much, I believe that the nausea was 
caused by some trouble with the kidneys. 
I never saw a wound do better, and the 
abdomen was perfectly flat on the first day 
after the operation. 

Dr. E. R. Palmer: My idea of the case 
is that death was caused by kidney lesions, 
such conditions any man who examines 
much for life insurance will often recog- 
nize. It is very common to find bad kid- 
neys in young men, and I believe in this case 
a defective kidney was the cause of death. 
Of course the exciting cause was the oper- 
ation, and the consequent shock. 

Dr. A. M. Vance: I saw this patient 
in the emergency, and recognized the 
probable nature of the coma and was very 
much interested in the case. It occurs to 
me that probably this man may have had 
septic nephritis — that there may have been 
a septic inflammatory condition of the kid- 
ney. I think it would have been very in- 
teresting to have held a post-mortem on this 
case to determine whether it was ordinary 
nephritis, or septic nephritis. This small 
accumulation of pus might have been suffi- 
cient, though he did not show marked evi- 
dence of sepsis generally. It is certainly a 
very interesting case, and one that proves 
to us the rightful procedure, of always mak- 
ing a very thorough examination of the 
renal secretions whenever possible. 

Dr. E. R. Palmer: Of course I am 
particularly interested in cases of renal 
lesions as a factor in fatal results, and 
those of us who are working strictly in 
that direction know how important it is 
to have a very careful analysis made of the 
urine, not simply a chemical albumen test, 
but a very careful examination of the sedi- 



January 14, 1893. 



Society Reports. 



55 



ment to try and determine if there be any 
renal trouble, and the nature and extent of 
it. But the point I want to make, and I 
have thought of it often, is that in this 
age of rapid advances of a more purely 
scientific nature in surgical work, that we 
do not insist enough upon post-mortem ex- 
aminations. I do not see why every city 
should not have one or two men who are 
known as "Post-Mortem Experts." I have 
seen a number of post-mortems where there 
was extensive degeneration of the liver, for 
instance, in which there was not a suspi- 
cion of liver complication during life, and 
consequently no treatment instituted for 
that organ. I believe in the case reported by 
Dr. Chenoweth, if a post-mortem had been 
held it would have been found that the 
man had serious renal trouble which prob- 
ably existed prior to the operation for ap- 
pendicitis. 

Dr. W. C. Dug an : I had the pleasure 
of seeing this case on the fifth day after 
operation with Dr. Chenoweth, and the 
patient was then suffering from nausea, 
otherwise he seemed to be doing very well ; 
pulse about 78, and did not indicate sep- 
sis. I am sure the patient died of uraemic 
coma as stated by Dr. Chenoweth. The 
question of coma after operation is one of 
great interest, especially as I have lost two 
patients recently from this cause, but the 
coma in both instance came on immedi- 
ately. Post-mortem revealed disease of 
the kidney in both cases and neither of 
the patients had any urine after the oper- 
ation. 

I am sorry that Dr. Chenoweth/s patient 
died, as it will go down as a . fatal case of 
appendicitis, when the operation for this 
trouble was a complete success, the patient 
eventually dying from another cause. 

Dr. J. M. Mathews : I think the Doc- 
tor should be commended for the diag- 
nosis he made. I have no doubt that in 
the country districts, and perhaps some- 
times in the city, patients have been al- 
lowed to die with appendicitis — so-called 
biliary colic, passage of gall-stone, etc. — 
without operation, when they might have 
been saved by surgical interference. In 
regard to the contents of the appendix in 
these cases, there is a popular impression 
existing, not only among the laity, but 
the profession, that it contains grape seed 
and other foreign bodies. Now, it always 
occurred to me that in the majority of 
cases the contents will be found to be fecal 



concretions. I notice Dr. Chenoweth in 
his report stated he found a fecal concre- 
tion. 

Dr. W. C. Dugan: In this connection, 
I remember looking up the subject some- 
time ago, and out of 252 cases of appendi- 
citis reported by several pathologists, 
there were irritating bodies found in the 
appendix in 112; and out of this number 
there were ninety-nine which contained 
fecal concretions or enteroliths, and in 
thirteen there were found various kinds of 
fruit seed or some other foreign body. In 
the majority of cases I am quite sure there 
is no foreign body. The hobby of grape 
seed, blackberry seeds, etc., is entirely a 
mistaken idea, in my judgment. 

Dr. Jas. Chenoweth : As to the cause 
of the trouble in this case, I think if you 
will examine the specimen you will find 
the opening into the bowel was very small, 
and probably the attacks he had before 
were simply produced by the appendix 
becoming distended by fecal matter. The 
concretions were not very hard. I think 
the irritation was caused by the distension, 
and then threatened gangrene from the 
pressure. As for the uraemic coma, I be- 
lieve as I look back on the case that the 
man undoubtedly had disease of the kid- 
neys prior to the attack of appendicitis 
for which the operation was performed, 
and believe that the kidneys were respon- 
sible for the way he acted under chlor- 
form; he was very much cyanosed and 
nauseated, more than could be accounted 
for in any other way, at the time, and after 
the operation. He had no septic symptoms 
at all as far as the wound was concerned; 
there was simply a small collection of 
fluid at the bottom of the wound between 
the peritoneum and muscles. 

Dr. Jno. G-. Cecil presented a paper, 
"The Curette in Obstetric and Gyneco- 
logical Practice." (See page 50). 

DISCUSSION. 

Dr. E. E. Palmer: I think Dr. Cecil's 
paper is one of the best that has ever been 
read before this society. I have a num- 
ber of cases of gonorrheal endo-cervicitis 
and metritis constantly under treatment, 
and in the management of these cases I 
have been doing a good deal of rough cur- 
etting, but with a dull instrument. I 
have had no trouble in passing the curette 
to the fundus and following the doctor's 
suggestion of beginning at a certain point 



56 



Society Reports. 



Vol. lxviii 



and returning to that point, curetting the 
entire interior of the uterus, removing a 
considerable quantity of muco-purulent 
material ; there has usually been consider- 
able bleeding following the operation. 
The last patient I operated upon was to 
have returned to-day ; whether there has 
been a continuous hemorrhage or not, I 
am not informed. I am certain, however, 
if there had been any further trouble I 
would have heard of it. I am very 
favorably impressed with the idea of free 
curetting. I have frequently irrigated 
the uterine cavity with 1 to 500 bichloride 
of mercury solution. If there exists an 
obstructed or diseased tube, then I carry 
my syringe up into the uterus directing 
the point toward that tube, and throw a 
stream of 1 to 500 bichloride solution, 
hoping it will go into the tube rather than 
with the fear that it may go into it. 
There is no question but that a great deal of 
this solution is left in the uterine cavity 
afterwards. I rather hope that some may 
be left there. I must say that in my 
experience, extending over more than 
twenty-five years, I have never seen any 
bad results further than an occasional 
sharp pain for a half hour or so, follow a free 
washing of the interior of the uterus. 
Of course my attention to the uterus now 
is confined almost entirely to that organ 
when it is probably the seat of venereal 
lesions. I shall certainly provide myself 
with a sharp curette and use it hereafter 
in these cases in preference to the dull 
instrument I have heretofore used. 

Dr. F. 0. Simpson : Just in this con- 
nection, I want to say that in the last 
week I have had occasion to curette the 
uterus of a woman who had aborted, fol- 
lowed by continuous flooding. I went 
over the whole cavity with a dull curette, 
removing quite a quantity of fungus ma- 
terial. She returned to-day and reported 
that the hemorrhage had entirely ceased. 
I examined her with a speculum and 
found a healthy condition. There was 
some little granulation around the open- 
ing in the cervix, but she had been 
relieved of that uncomfortable, heavy 
feeling, and bearing-down sensation. I 
simply mention this case to corroborate 
what has been said concerning the use of 
the curette. 

De. J. G-. Cecil : I have very little to 
say in closing. In dilatation of the cer- 
vical canal I have never used tents at all. 



I can frequently accomplish dilatation in 
a very little time to such extent as to 
admit of the free and easy use of the cur- 
ette without anaesthesia, using a G-oodell 
dilator. I simply dilate the cervical canal 
sufficiently to enable me to freely use the 
instrument, no further. I am very sorry 
that the limits of my paper would not 
admit of a detailed report of a number of 
cases both in obstetric and gynecological 
practice. I am more particularly inter- 
ested in the use of the curette in gyneco- 
logical than in obstetrical cases, and while 
this is a Surgical Society, still the question 
of its use in obstetrical cases demands 
some attention. I should have been very 
glad to have heard a discussion upon the 
use of the curette in obstetrical cases. 
While the cases I have referred to as being- 
followed by uniformly good results in the 
University outdoor clinic, many of which 
have been put in a carriage and driven 
two, three and four miles, those results 
were obtained in gynecological cases, but 
I have had equally as satisfactory results 
in obstetric cases ; and this was the point 
I wished particularly to hear discussed. 
I think the fear in regard to the use of 
the curette has been much magnified in 
the minds of many obstetricians. 

Concerning infection of the puerperal 
womb : I have in mind now the case of a 
young woman who miscarried at three or 
four months, and had evidences of septic 
infection, so much so that her attending 
physician became very uneasy. I put this 
patient upon the bed and without anaes- 
thesia irrigated the womb thoroughly, and 
with a dull curette scraped away every- 
thing from the cavity, and had the satis- 
faction of seeing the woman make a per- 
fect recovery without any further infec- 
tion. I have recently been very favorably 
impressed by an article, by Pryor, of New 
York, on this subject. He takes the posi- 
tion (and I perfectly agree with him) that 
we ought not to allow patients to die of 
septic infection of the womb without giv- 
ing them the opportunity of the advantage 
and benefit to be derived from the curette, 
at least the possible chance of preventing 
the spread of infection and limiting that 
which has already been observed. I 
think before many years have elapsed the 
curette will be used in common practice. 

PATHOLOGICAL SPECIMENS. 

Dr. W. L. Rodman : The patient from 
whom this specimen (Testicle) was re- 



January 14, 1893. Society Reports. 



57 



moved gave the following history : He was 
an exceedingly robust, vigorous young man, 
about twenty-four years of age, sent to 
me by a medical friend ; I saw him for the 
first time about ten days ago. He had a 
hernia on the right side, which he tells 
me was cured by a trass, and had been 
cured for five or six years. He had a 
retained testicle on the left side. The 
testicle, which was small in size and soft 
in feel, was found located just in the 
external abdominal ring. It was not 
possible to pull the testicles down into the 
scrotum, on account of the shortness of 
the cord. Owing to its very soft consis- 
tency, and the probable functional inac- 
tivity, I advised immediate removal. The 
patient consented conditionally, saying 
that, of course, he would like to have it 
removed, provided there was no chance of 
saving it. I told him that when we cut 
down upon the testicle if we found it in a 
healthy condition, an effort would be made 
to preserve it by transferring it to the scro- 
tum, I operated upon it and after cutting 
down around the organ, found it very small 
and even softer than I suspected, and that 
it had undergone cystic degeneration. The 
testicle was immediately removed, trans- 
fixing the cord and tying each way. I 
am inclined to the opinion that all re- 
tained testicles, even in the inguinal canal, 
or outside of the external ring, should be 
removed. When retained in this situation 
they are usually small and imperfectly 
developed organs, without function and 
there is a decided tendency to undergo 
sarcomatous change. 

DISCUSSION. 

Dr. A. M. Vance : I have seen a great 
many cases of this character, and believe 
in the majority of them the testicles are 
practically useless. 

Dr. E. E. Palmer: I believe that all 
testicles retained anywhere in the canal, 
are not only useless, but are dangerous; 
in the abdominal cavity they may be active 
and useful. I have already reported one 
case of a bridge builder who came to me 
for treatment for another trouble, having 
incarcerated testicles in the groins. He 
called my attention to this condition and 
asked me if I thought he could get mar- 
ried. I told him that I believed he was 
sterile, but to bring me a sample of his 
semen and I would make an examination 
of it. This was done and I found the 



semen utterly devoid of spermatozoa. 
He did marry but his wife never con- 
ceived. I have never seen a case of malig- 
nant degeneration of the testicles from 
being retained and have seen a great many 
monorchids and cryptorchids. 

Dr. A. M. Vance: I have treated a 
great many cases for replacement of the 
testicles, and have often succeeded. I 
have a case under treatment now where a 
surgeon in town had applied a truss over 
the testicle with the idea of pressing it 
back into the belly. A number of times 
have I taken trusses off from retained 
testicles being treated for hernia. In the 
case above referred to in which there had 
been an effort made to force the testicle 
back into the abdominal cavity, I have 
succeeded in getting it down in a month 
or six weeks into the top of the scrotum 
by the application of a truss over it and 
careful manipulation. I believe in the 
majority of infantile cases, where the tes- 
ticle is out of the canal at all, or even ap- 
proaching the external ring, it can be re- 
placed into the scrotum by a little patience 
on the part of the mother. 

Dr. W. C. Dugan : I believe that Dr. 
Rodman did exactly right in removing the 
testicle, as, when retained in the canal 
they are very prone to undergo malignant 
degeneration. The question I want to 
bring up is this, and, as I have stated be- 
fore, — when these cases come under our 
observation early in children, if everything 
else has been tried, and the testicle re- 
mains in the canal, and we cannot get it 
down, and the mother and father are very 
anxious to save the testicle, — inasmuch as 
we know that when these testicles are in 
the cavity of the pelvis, they are normal 
and serviceable, and a testicle in the canal 
is subjected to pressure and liable to 
undergo malignant or inflammatory degen- 
eration, that these testicles should be put 
back into the pelvis. I think this will be 
the operation in the future. 

AN INSURANCE QUESTION. 

Dr. W. L. Rodman : I have seen in the 
last few days the most remarkable case 
that I have ever seen in my life — the most 
deplorable ending to it. Last Thursday I 
saw a gentleman for an accident company, 
about fifty-five years of age, laborer in one 
of the breweries of this city, who, by some 
accident, had sustained a simple fracture 



58 



Society Reports. 



Vol. lxviii 



of the distal phalanx of the great toe near 
the joint. I saw him for the first time 
Thursday afternoon, after considerable 
swelling had taken place. I ordered hot 
applications, saw him again Friday and he 
seemed to be getting along all right. I 
saw him again on Saturday afternoon, five 
o'clock, and noticed he was a little ner- 
vous. His wife said that he had some 
fever in the forenoon, but did not seem to 
have any when I saw him at five o'clock 
in the evening. I did not use the ther- 
mometer, however; he said he was feeling- 
very comfortable, and remarked that the 
hot water had relieved the pain. I told 
him he was doing so well that I would not 
call again until Monday. I learned to-day 
(Monday) that he was dead. I at once 
went to the brewery to learn the particu- 
lars and found that on Sunday morning 
about two o'clock he had jumped out Of 
the second story window; did not hurt 
himself much in jumping; wandered 
around town, went to the brewery and re- 
mained there two or three hours; bought 
two bottles of whiskey (pint bottles) and 
wandered out to the country and was seen 
six or seven miles from town yesterday at 
noon. He was very thirsty and went to a 
farmer's house, and asked for a drink of 
water, then tried to climb up the side of 
the stable, saying that he wanted to get 
into his room. He wandered about all 
yesterday and was found dead about four 
o'clock this morning with two empty pint 
bottles in his pocket, having evidently 
contained whiskey. This man had been 
working at the brewery and had probably 
been in the habit of drinking a great deal 
of beer; when I saw him on Saturday 
afternoon I did not tell him to drink more 
or to drink less. I thought as he was a 
little nervous possibly he was not getting 
quite as much beer as he was accustomed 
to. The question is, what ought the acci- 
dent company to do in a case of this kind. 
I am very frank to say that the man may 
have had delirium, even as a result of a 
slight injury like that. It is questionable 
as to how much was due to whiskey, and 
how much was due to fever, the result of 
this simple fracture of the distal phalanx 
of the great toe. 

I remember reporting to this Society 
four or five years ago a case of delirium 
after fracture of the leg. I held at the 
time that the delirium was due to the 
fracture. 



DISCUSSION. 

Dr. E. E. Palmer: My experience 
with these men who work about breweries 
and about beer saloons, and who are con- 
stant beer drinkers, is that they usually 
wind up the day with whiskey or brandy; 
that beginning the next morning they 
drink whiskey or brandy, which, in both 
or either instance, is usually a very infer- 
ior article, and begin their beer again 
about ten o'clock in the day. I think the 
case reported is clearly one of surgical de- 
lirium in the drinking man. 

Dr. W. 0. Dugan: The question is 
whether the accident company should 
pay the amount of insurance. — I think 
they should. Why? Because, undoubt- 
edly, the fact was known that the man in 
question was a drinking man at the time 
the insurance was taken out. The com- 
pany assumed the risk, and, I think, 
should pay for it. It may be true that the 
man developed delirium tremens, and he 
was practically predisposed to it. On the 
other hand, his death might have been the 
result of ursemic coma. 

Dr. H. H. Grant: I have seen a great 
deal of delirium tremens, and it has been my 
observation that it nearly always occurs, 
for some reason, after fracture or other 
minor injury. In the case reported by 
Dr. Eodman, I do not think the man 
would have sustained the injury if he had 
been carefully watched and properly 
nursed. I believe it is fair to decide that 
the accident was not the cause of this 
man's death, but it was the predisposing 
cause. I do not think the accident com- 
pany is responsible for the reason that the 
man was under the care of his family and 
should not have been allowed to jump out 
of the window, subjecting himself to that 
risk. I think the position taken by Dr. 
Dugan is hardly the proper one for us to 
hold. 

Dr. W. L. Eodman: I failed to state 
that this man lived up stairs with his wife, 
who is an invalid, and, therefore, not 
able to restrain him. I shall certainly ad- 
vise the company to pay the insurance. 
Had he not received the injury, he would 
not have had delirium tremens. 



Many cases of death are caused from 
vasomotor paralysis of the heart, superin- 
duced by the administration of alcohol in 
the practice of physicians. — Quirmby. 



January 14, 1893. Society Reports. 



59 



THE CLINICAL SOCIETY OF LOUISVILLE. 

Stated Meeting of December 18th, 1892. 



DOUBLE EXCISION OF THE KNEE. 

Dr. A. M. Vance: I simply present 
this patient to show the result of double 
incision of the knee for infantile paraly- 
sis. The boy is about nine years old, 
very small for his age ; his body is fairly 
well- developed but the legs are very 
small. I first operated upon the left leg, 
then after a lapse of about five months 
excised the right knee. You will notice 
I have put one leg in slight flexion, the 
other in hyper-extension, by this means 
hoping that he may be better able to bal- 
ance himself in walking. I used no 
suture whatever in uniting the bones, the 
plaster dressing serving to keep them in 
apposition; I first removed the patella, 
then about a half inch of the tibia and 
femur. There has not been the slightest 
sign of inflammatory reaction or suppu- 
ration from either operation, proving the 
power of asepsis in these cases. I have 
done this operation five times on the knee, 
and twice on the ankle; the last patient 
operated upon died about ten days after 
the operation with some trouble of the 
heart. 

DISCUSSION. 

Dr. I. N. Bloom: In case the oper- 
ation had not been performed and the 
paralytic condition allowed to exist there 
would have been complete atrophy of the 
muscles. I would like to ask Dr. Vance 
if he expects muscular development now. 

Dr. A. M. Vance : All the calf muscles 
that move the foot and are not paralyzed, 
will develop by use. 

Dr. W. 0. Roberts : There seems to be 
a good, bony union. Have you ever no- 
ticed in any of these cases, after you have 
apparently secured good, bony union, it 
afterwards limbers up ? 

Dr. A. M. Vance : No, I have not ; the 
bony union has always been permanent. 

Dr. W. 0. Roberts: One important 
point in an operation of this character is 
to get, if possible, bony union, and in 
order to do that it seems to me you are 
bound to take off the cartilage of both 
bones. If you do not you get what is 
called a "flail" joint. Another point you 
have to be exceedingly careful about in 
removing a piece of bone is, not to take 
off too much ; if you do the bone ceases to 



grow. This is a very important point in 
cases of resection in children. 

CASES EXHIBITED. 

Dr. T. P. Satterwhite : Dr. Dugan, I 
believe, performed a laparotomy upon this 
patient about a year ago; the stitches 
inserted at the time seem apparently to 
have cut through, and there is a kaloid 
condition running across the abdomen 
from each stitch as large as a small lead- 
pencil. She is a Polish girl about eigh- 
teen years of age. The operation referred 
to, as I understand, was an exploratory 
one, owing to some ovarian trouble which 
was supposed to exist. However, every- 
thing was found to be in an apparently 
healthy condition, consequently nothing- 
was removed. 

The point that I wish to call particular 
attention to is, that she now claims to 
have an evacuation of the bowels only 
once in three or four weeks. She speaks 
English so imperfectly that it has been 
exceedingly difficult for me to obtain a 
full history of the case. She tells me that 
she suffers intensely, probably from the 
accumulation of fecal matter, and that a 
colotomy has been proposed for her relief. 
That is a point upon which I desire to ob- 
tain the judgment of the Society — as to 
the propriety of further operation. She 
came to me for advice as to whether she 
should submit to an operation. She says 
that one-half of her body, (left side) is 
perfectly devoid of sensation; a needle 
can be thrust into the body on that side 
without pain ; there is perfect sensation of 
the opposite side.- There is no loss of mo- 
tion of any portion of the body, but sim- 
ply loss of sensation on one side, which 
has existed for about eleven months. She 
has been troubled with constipation for 
about a year. 

Case II. Many of you have seen this 
patient as he has been in the city hos- 
pital a greater part of the time for the last 
year or so. I simply had him come here 
to show the development of the superficial 
veins on the upper part of the trunk. These 
veins commenced enlarging about a year 
ago and you will observe now they are 
nearly as large as your finger. A peculiar 
feature is that the blood flows downward 



60 



Society Reports. 



Vol. lxviii 



in these veins, as can easily be proven by 
compressing them at either extremity. 

DISCUSSION. 

Dr. W. H. Wathen : If I understand 
correctly, one of the especial reasons for 
reporting the first case, was to get the 
sense of the Society as to whether colotomy 
is indicated. This woman consulted me 
some six weeks ago upon two or three oc- 
casions, but I found that she was not a 
patient that would interest me especially, 
and declined to see her again. I can see 
no indication for a surgical operation of 
any kind upon her bowels, or upon her 
uterus or its adnexa. Colotomy could do 
no possible good, but might do a great 
deal of harm, because it would bring 
about a very disageeable condition by 
keeping the patient constantly soiled 
with fecal matter. I can not understand 
why colotomy should have been suggested, 
because there is no apparent obstruction 
in any part of the canal, and we have no 
positive assurance that this woman has 
constipation at all. In fact, I am inclined 
to the opinion that she is having evacua- 
tions with comparative regularity. I do not 
mean to claim that she is purposely de- 
ceiving the profession, for she may be 
absolutely honest in what she says; she 
is probably insane upon the subject. 
Were she having as few evacuations as she 
claims, there would be conditions that do 
not exist. 

Dr. T. P. Sattbrwhite : In regard to 
what Dr. Wathen has said: "That there 
would be some constitutional disturbance 
if a patient did not have an evacuation 
oftener than stated by this patient," let 
me state : Several years ago I had an Irish 
servant girl with me about thirteen years, 
and she never had an action of the bowels 
for three and four weeks at a time and 
during this period she was in excellent 
health. Never was sick in the thirteen 
years, and she reported to me at the time 
that there was a woman next door in 
exactly the same condition. 

Dr. I. N. Bloom : You are all doubtless 
familiar with the report in physiology of a 
man who went eight months and sixteen 
days without having an action of the 
bowels, and was in perfect health all the 
time, and when he did have an action 
there was a large amount of fecal matter, 
over fifty pounds, I think. Oases of this 
kind are not so very uncommon. An ex- 



amination of the abdomen is bound to dis- 
close an abnormal condition, while the 
sensations of the patient may be those 
perfectly consistent with good health. 

Dr. A. M. Vahce : I have seen a great 
many cases of varicose veins on the trunk, 
and do not think the condition very un- 
common. I expect I have seen at least 
twenty-five cases, some of which are more 
marked than the one shown by Dr. * 
Satterwhite. 

GANGRENE FOLLOWING FRACTURE OF ARM. 

Dr. W. 0. Roberts : About two weeks 
ago I was called to a neighboring town to 
see a gentleman who had fallen a distance 
of some twenty feet, sustaining a compli- 
cated fracture of the bones of the forearm. 
The arm was put up in plaster dressing 
and kept there several days. At the end of 
the week his physician discovered evidence 
of gangrene. When I saw the patient, seven 
days after receipt of the injury, gangrene 
was quite marked and extended to within 
two inches of the elbow joint. The parts 
above were very much swollen, and there 
was considerable contusion and ecchymosis 
of the arm on the inside, as high as the 
axillary space. The patient's temperature 
was 104° F., pulse 130. The temperature 
the day before, the doctor told me, was 
only 101° F. ; on the morning of the day I 
saw him it was 102° F. I saw him about 
four o'clock in the afternoon and advised 
immediate amputation, and did the opera- 
tion at the junction of the middle third 
of the humerus. I had a letter from the 
doctor, a week after the operation was 
performed, saying that at nine o'clock at 
night of the day of the operation the 
patient's temperature had fallen to 100° F. 
and since that time it had not gone above 
99°, and that there was union nearly 
throughout the whole line of the incision. 



Excision of the tympanum and ossicles 
gives beneficial results only in about forty- 
six per cent, as to the tinnitus, but no 
noticeable improvement in the hearing. 

Doctors, lawyers and divines in our 
American civilization are prone to use to- 
bacco, not simply for its sedative effect, 
but for companionship, and so to use it to 
excess. 



The Medical and Surgical Reporter 



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Saturday, January 14th, 1893. 



EDITORIAL. 



A DEPARTMENT OF PUBLIC HEALTH. 



Why not establish a National Depart- 
ment of Public Health, with its chief a 
member of the Cabinet? The present 
seems to offer a most favorable opportun- 
ity. The subject has been frequently dis- 
cussed of late years, but apart from the 
establishment of a national quarantine 
supervision, no suggestion on this line has 
been made since the subsidence of the late 
cholera excitement. 

None but a cavilling patriot or a ward 
statesman would deny the usefulness of 
the Department of Agriculture. It has 
rendered good service within its sphere. 
At any rate, it has succeeded in restoring 
the position of the American Pig abroad. 
It costs some million dollars to do this, 
but it secures large profits for pork packers 
and enables them to maintain without cost 
their representative in the foreign market. 

While thus insuring his alien friends 
against infection from " pork measles," 
the American tax payer maintains his per- 
sonal liberty to enjoy all the privileges and 
delights to be secured from Trichinosis. 
Indeed he could hardly do otherwise for it 



would require Federal watchfulness and 
authority to secure him immunity, and 
this could not be had without infringing 
on State Rights. Any national laws to 
regulate adulterated or impure food pro- 
ducts must meet with the same objection. 

If the Federal Government is able to 
spend money liberally to investigate the 
ills that animals are heir to, and to enforce 
measures to prevent and cure such ills; if 
it can indulge in costly efforts to make 
sterile lands fertile; if it can explode 
thousands of dollars in making stage- 
thunder, hoping to seduce cloudless skies 
into surrendering rain ; if it can control and 
regulate interstate commerce — it would not 
seem an undue centralization of power to 
charge the National Government with the 
care of the health and happiness of the 
citizens of states which are inter-depend- 
ent in this matter perhaps more than any 
other. 

Of course if public health were raised 
to a plane that required it to support the 
tremendous dignity of a government "De- 
partment " and 



62 



Editorial. 



Vol. lxviii 



"Show the force of temporal power, 
" The attribute to awe and majesty, 
" Wherein doth sit the dread and fear of Kings" 

it is altogether probable that its beneficial 
action would be clogged by that network 
of red tape which seems necessary to prove 
the existence of governmental undertak- 
ings. But with all its pretentious formality 
it would be infinitely better than the system 
now obtaining, where the health officer is 
the creature of local politicians and the 
office is used to repay political obligations 
without reference to its importance or to 
the qualifications of the incumbent. 

The health officer in any large seaport 
may, from a position of comparitive insig- 
nificance, suddenly be charged with respon- 
sibilities that would strain to the utmost 
the resources and capabilities of the best 
trained and most experienced scientific 
specialists of the world. It is simply im- 
possible for any ring-trained politician to 
rise equal to such an emergency. Only a 
thorough scientist supported by the power 
of the Federal government can successfully 
contend with the Devil of Moneyed Inter- 
ests on the one hand and, on the other,, 
the Deep Sea of the Welfare of sixty-five 
millions of people. 

Two measures have been presented to 
Congress as steps toward securing national 
quarantine control ; at best but wretched 
caricatures of what is needed. One pro- 
poses to attach quarantine to an existing 
branch of the service, which might be 
able to care for it if it had nothing else to 
do. The other proposes absolutely noth- 
ing. 

The first measure, now pending in the 
Senate, is apparently objectionable to cer- 
tain disinterested patriots. For it threatens 
injury to the steamship companies con- 



cerned, in that it does not consider 
their dividends superior to the welfare 
of United States citizens. Again it 
appears to be totally oblivious to the time 
honored rights of ' ' effete monarchies " to 
unload their paupers and criminals on 
American Institutions. Finally it un- 
winds the swathing bandages of that 
mouldy mummy States Rights. 

As the bill is constructed on the " nickle- 
in-the-slot" principle the insertion of 
sufficient plaques might bring out enough 
amendments to remove these and all other 
objections. 

It may be noted that States Rights were 
not pressed with any degree of persistence 
when the Marine Hospital Service was 
detailed to stamp out yellow fever in 
Florida, and saved the nation from a 
(i visitation of wrath " that the combined 
" righteousness " of local health author- 
ities could not have averted for a mo- 
ment. 

Quarantine is not the only function of 
such a department. It is not the chiefest 
even. The immense subject of vital sta- 
tistics in its myriad ramifications is of un- 
told value to the nation, practically as w r ell 
as scientifically. 

If infectious or contagious disease among 
animals is of sufficient importance to re- 
quire government authority for investiga- 
tion, prevention and cure, it would not 
seem unreasonable nor yet undesirable for 
the government to undertake the watch- 
care of analogous conditions in man. If 
it could be accomplished in no other way, 
it might possibly be smuggled into the 
department of Agriculture under the plea 
that man is only an " articulate speak- 
ing " animal. 



GYNECOLOGY AMONG THE INSANE. 

The secular papers with an inspiration brutal, inhuman and not excusable on any 

commendable for energy rather than dis- reasonable ground," the practice of gyne- 

cretion, announce that the State Board of cological surgery upon insane women at 

Charities has prohibited, as " illegal, the Norristown Hospital. The breeze is 



January 14, 1893. 



Editorial. 



63 



caused by the alleged action of Dr. Ben- 
nett in allowing operative procedures to be 
undertaken on a series of cases in hopes of 
relieving or curing the mental conditions 
by removing the probable physical causes. 
The State Board is fortified by an opinion 
from its legal member, which opinion 
shows better acquaintance with law than 
with medicine. We venture to say that 
Dr. Bennett has permitted no operation 
where there were not gross indications of 
actual disease such as would compel urgent 
measures in the sane. 

However it may be of some benefit to 
the profession to have this moot question 
definitely settled by the State Board of 
Charities and its legal member thus early 



in the investigation. We hope these 
authorities will not rest idly content until 
they have definitely settled, at least to 
their own satisfaction, the "illegality, the 
brutality, the inhumanity and the inex- 
cusability " of cerebral surgery in cases of 
mental disturbances caused by old de- 
pressed fractures, tumors, abscesses and 
the like in the brain. 

Perhaps it is true humanity to keep the 
irresponsible wards of the state intact in 
their insanity, but it is doubtful if even 
the savants of the State Board of Chari- 
ties would hesitate to invoke any means of 
relief, even such brutal and inhuman ones, 
were the unfortunate victims closely re- 
ated to themselves. 



THE BOARD OF HEALTH. 



During the last four weeks the number 
of cases of diphtheria reported to the 
Board of Health has ranged from 144 to 
154, and the deaths from 36 to 62 weekly. 
The Board has guarded more or less 
efficiently those houses in which the di- 
sease has had its victims. This has been a 
necessary precaution which should not 
have been suspended for a single hour, 
but it appears that on the 28th of Decem- 
ber the Health Officer withdrew from the 
scenes of the disease all watchmen em- 
ployed by the Board, for the stated reason 
that the appropriations for 1892 had been 
exhausted. On the following day, how- 
ever, it was discovered that such was not 
the case, and, consequently, some of the 
watchmen were reinstated and the quaran- 
tine about the infected houses again set 
up. 

That the quarantine was intermitted 
for a day or an hour was a mistake. The 
Health Officer, -if the Board's treasury 
were really empty, should have given the 
watchmen persoual assurance of their be- 
ing ultimately paid, or he should have 
consulted the Mayor, who could have got 
in an hour subscriptions from citizens 
sufficient to pay for guarding every dan- 
gerous point. The Health Officer, in 
such an emergency, could have got the 
little money needed for a purpose so 
nearly affecting the health and lives of 

I 



the community at the Ledger office, or 
from any one of a hundred other offices 
near at hand, where it would have been 
willingly advanced or presented him. 
There was no valid excuse whatever for 
suspending the quarantine of the diph- 
theria cases for a day or an hour. 

The large number of deaths which have 
occurred from this disease during the year 
past, the larger number of cases and the 
continued prevalence of the malady sug- 
gest that the Board of Health is not con- 
spicuously competent to deal with a con- 
tagious disease which has got so strong a 
foothold and the mortality from which is 
so great. 

The Board of Health proposed, and in 
its treatment of Philadelphia's commerce, 
used truly remarkable means to prevent 
cholera entering the city. Its quarantine 
policy and methods were, and still are, as 
antiquated, crude and clumsy as they well 
could be. They appeared to be intended 
rather for the crippling of commerce than 
for protecting the public health. 

Take as an example of the practices of 
the Board its treatment of certain passen- 
gers on the Indiana the other day. On 
the last voyage of that ship three children 
developed scarlatina ; they were at once 
isolated from the passengers in another 
part of the vessel, and given the best med- 
ical attention. No other cases had oc- 



64 



Abstracts. 



Vol. lxviii 



curred when the Indiana arrived 'at her 
dock on December 31st, nine days after 
the third and last case had developed. 

But under orders from the Port Physi- 
cian, by instructions of the Board of 
Health, the three children referred to, and 
all other members of the families con- 
nected with them, together with all the 
other children under twelve years of age 
aboard the ship, and all the other members 
of their families, were placed in ambu- 
lances, provided by the Board of Health, 
and driven through the cold streets to the 
distant Municipal Hospital, commonly 
known as the City's Pest House, and 
largely occupied at the time by diphtheria 
patients. All those persons were kept in 
this place of contagious diseases until Jan- 
uary 4, when they were returned to the 
vessel. Prior to their removal to the 
hospital the steamship agents recom- 
mended to the health authorities that all 
passengers who were regarded as suspects 
should remain aboard the Indiana, where 
they could be isolated and receive the best 
treatment and attention, at the company's 
sole charge and expense, instead of being 
hauled through the streets to the pest 
house, but the offer was refused. 

Inquiry made at the German, Jefferson, 
Philadelphia, Hahnemann, Jewish, Univer- 
sity, Medico-Ohirurgical, Pennsylvania, 
Presbyterian, Episcopal and St. Agnes's 
Hospitals shows that neither of these insti- 
tutions receives diphtheria patients, and the 
Board of Health has ordered that all such 
cases shall be sent to the Municipal Hos- 
pital. In view of the fact that that insti- 
tution has not the resources, facilities or 
appliances for treating the diphtheria in 
the most effective manner, and as the 
Port Physician, in a letter dated January 
1st, 1893, stated that the city is " engaged 
in a desperate struggle with an epidemic 
of diphtheria, 1 ' would it not be reasonable 
that some provision should be instantly 
made for treating aggravated cases of the 
disease, and also for providing a head- 
quarters where poor patients, at least, 
could be promptly treated by the most 
skilled physicians ? Why should there 
not be promptly established a diphtheria 
hospital? It will be noticed that, accord- 
ing to indisputable evidence, cases are 
commonly left to be treated in the place 
of their origin, be it a mansion or a small, 
crowded household of the very poor, and, 



even with such a condition of affairs, all 
possible physical restraint as to the inter- 
mingling of the inmates of the various 
houses in which diphtheria existed was 
removed for a time, as recently as Thurs- 
day, December 28th, 1892, through the 
removal of watchmen from quarantined 
houses. 

Common sense would seem to indicate 
that, as Philadelphia has suffered during 
the last few months from what is desig- 
nated by a prominent health authority as 
" a scourge of diphtheria," some steps 
should be taken to stamp out the disease, 
which is amongst us in visible form, rather 
than to concentrate the efforts of the 
Board of Health upon crude schemes to 
repel a no more dangerous scourge, which, 
it is only conjectured, may appear in our 
vicinity within the next four months. 
Not a single suspected case, even, of chol- 
era, so far as is known, was brought to 
this port by any ship last summer. 

A diphtheria hospital could be estab- 
lished at once, and, if placed under expert 
management, the funds to carry it on 
would not be lacking. 

Meanwhile, the Board of Health should 
do something to show that it is entitled to 
public confidence. Its quarantine meth- 
ods, as applied to ships or houses, are not 
of a sort to give assurances of its intelli- 
gent appreciation of what is best to be 
done, or how to do it. — (Ed. Public Led- 
ger, Jan. 10, 1892.) 



Effect of Intranasal Obstructions on the 
Singing Voice. 

Dr. A. B. Thrasher {Cincinnati Lan- 
cet-Clinic) says: 

Intra-nasal obstructions are a common 
and serious cause of disorders of the sing- 
ing voice. 

Generally the obstruction is accom- 
panied by an affection of the soft palate, 
and less frequently by pharyngeal and 
laryngeal disease. 

When there is simple intra-nasal ob- 
struction not complicated with palatal, 
pharyngeal, or laryngeal lesions, the tim- 
bre only of the voice is affected. 

When the movements of the soft palate 
are interfered with, then the upper reg- 
ister and the soft medium register are 
affected, in addition to an injury to the 
quality of the voice. — Am. Lan. 



January 14, 1893. Translations. 



65 



TRANSLATIONS. 

MARIE B. WERNER, M. D. 

NEW GROWTH OF THE UMBILICUS* 



This interesting monograph contains 
many important communications, which 
have been derived largely from the surgical 
clinic at Halle, while a number have come 
under the author's personal observation. 

The collection of 185 cases have been 
carefully studied and classified. This is 
the first of a series of studies on carci- 
noma which was inaugurated by the late 
E. Yon Volkman, and begun by his assist- 
ant shortly before his death. Pernice 
classifies the case under four heads : 

I. The\Infiammatory Processes of the Urn- 
Jnlicus. — Under this head he recognizes five 
forms, namely: 1. A case of navel-granu- 
lar. 2. A case of navel-gumma, (which 
had softened and thus had the appearance 
of a degenerating carcinoma.) 3. The 
navel concretions. 4. A case of a horny 
excrescence of the umbilicus. 5. Papil- 
lary fibroma, (these are placed under 
this head from the fact that they originate 
by a slow form of inflammation, the tumor 
developing slowly at its base. ) These cases 
studied in detail will prove of interest. 

The second chaper takes up : 

II. The Growths Originating in the 
Connective Tissue. — Under this head Per- 
nice reports: 1. Two cases of fibroma and 
fibro-lipoma. 2. Two cases of angioma. 
3. Nine cases of myxoma. 4. Fourteen 
cases of sarcoma and fibro-sarcoma. Eight 
of these came under the author's own ob- 
servation; among these he met with two 
cases of melanotic sarcoma. 

The author has devoted more time and 
study to the third class making it especially 
interesting regarding the origin of the 
various forms of malignant growths. His 
classification is as follows: 

III. The Growths from the Umbilicus 
Originating in an Epithelial Basis, Par- 
ticularly Carcinoma. — Pernice separates 
the primary from the secondary forms and 
since the value of this essay concentrates 
itself in this chapter, it becomes desirable 
to enter into a little more detail regarding 
its theories. 1. Primary Carcinomas, 
under which he reports 27 cases, among 
which the following differentiations are 

-Translated from the Central, f. Chirurg, No. 41. 
1892, for Medical and Surgical Reporter. 



observed : Cancroid, Papilloma degenera- 
ting into Carcinoma, Scirrhus, Tubercular 
Epithelioma, Colloid Carcinoma, Encepah- 
loid Carcinoma. In the greater portion of 
the first three mentioned their origin can be 
traced to the superficial layer of the epi- 
thelium. The second growth is charac- 
terized by epithelium similar to that 
found in the intestines. The explanation 
for the frequency of Cancroid may be 
found in the chronic irritative condition 
met within the collection and decomposi- 
tion of dirt and epithelial masses, hair, 
and sebaceous matter. Their growth is 
slow, frequently degenerating from papil- 
loma, and partake of an abscess or papil- 
lomatous appearance. The prognosis is 
relatively favorable. It is advisable to 
operate early and never to remove a sus- 
picious malignant growth without opening 
the peritoneum for careful inspection and 
removal of suspicious infiltrates. If the 
inguinal glands are enlarged they should 
-be extirpated. Scirrhus, which should be 
treated from the same standpoint, derives 
in all probability its origin from the epi- 
thelium of the skin, perhaps the most 
deeply seated part of the umbilical cicatrix. 
It is characterized by its relatively rapid 
growth. The prognosis is relatively more 
unfavorable. 

To the second group, whose origin is 
traced to the more deeply seated epithe- 
lium, belong the cases of Colloid and En- 
cephaloid Carcinoma. Their epithelium 
resembles that of the intestine, and they 
are, perhaps, closely related to the ductus 
omphalomesaraicus. (A swelling of the 
umbilicus may often be regarded as pri- 
mary when in reality it is simply a con- 
tinuation from a deeper seated growth; 
for example, an extension from a cancer 
of the stomach). Kapid growth into the 
deeper structure is characteristic of this 
variety, extending not only through the 
umbilicus but also into the peritoneum 
and abdominal organs. On several occa- 
sions small carcinomatous growths were 
observed through the peritoneum and upon 
the serosa of the liver. Frequently infil- 
trations have been noticed extending from 
the umbilicus to the liver, to the bladder, 



66 



Translations. 



Vol. lxviii 



in the suspensory ligament of the liver 
and the median vesical ligament, carried, 
no doubt, by the lymph channels. The 
inguinal glands were frequently found in- 
fected, but infection was rarely noticed in 
the retroperitoneal glands and never in the 
axillary glands. The prognosis is unfavor- 
able. 

2. Secondary Umbilical Cancer.-Of this 
variety he reports twenty-nine cases; 
twenty among women, nine among men. 
The primary lesion was usually some- 
where in the abdominal organs — stomach, 
uterus or intestines. The ages ranged 
from 33 to 73 years; the greater number 
of cases were found between the ages of 50 
and 60. All cases ended fatally in spite of 
numerous operative procedures. The 
growths were a sequence to the continued 
progression of the disease in twenty-four, 
and in five it appeared as a metastatic 
formation. 

In the first series of cases reported 
under this head, ten cases were described, 
in which there was direct adhesion of 
the cancerous mass to the umbilicus; 
thirteen where communications could be 
traced from the ligamentum suspensor 
hepaticus, and lastly, a case in which it 
followed the incarceration of a carcinomat- 
ous nodule of the omentum in an umbili- 
cal hernia, the primary growth having 
started in the uterus. The first ten cases 
were for the most part secondary manifes- 
tations of a primary cancer in the stomach, 
or an omental metastasis, cancer of the gall- 
bladder or intestines, which had become 
adherent to the umbilicus. Among the 
thirteen cases the primary affection in 
seven was of gastric origin, one of the in- 
testine, two of the uterus, three of the 
peritoneum generally. 

The metastatic formation of cancer in 
the umbilicus is rare if not in direct com- 
munication with the lymph channels, it 
seemingly being necessary to have a direct 
medium of interchange. The prognosis 
is unfavorable, operative interference hav- 
ing in all cases been hopeless from the ex- 
tensive infiltration. 

In a third group under the third class 
he places : 

3. Atheroma and Dermoids of the Umbi- 
licus. — He reports twelve cases. The 
treatment and its result is precisely the 
same as in other parts of the body. 

Under the fourth class the author 
places : 



IV. Adenoma and Enteroteratoma of the 
Umbilicus. — They apparently simulate the 
granuloma and are connected with the 
ductus omphalomesaraicus. Thirty-eight 
cases gathered from the literature and one 
case under personal observation are re- 
ported. Histologically, they are composed 
of two layers, a peripheral glandular layer 
and a smooth, muscular layer, and occa- 
sionally a thin, central connective tissue 
layer could be observed. The author does 
not approve of the names given this form 
of enlargement, since he is of the opinion 
that, generically speaking, adenoma does 
not express its mode of origin — not being a 
new growth — but a prolapsed diverticular 
portion of the tissues, and for that reason 
enterateratium is equally unsuited to de- 
scribe it. The author, therefore, proposes 
the name of diverticular prolapse of the 
umbilicus, which explains the nature of 
the swelling and its peculiar histological 
construction. 



A Case of Poisoning of flethylblue. 

An engineer was suffering from a typical 
attack of malarial fever and was treated 
with arsenic and quinine without success ; 
received some benefit from the use of 
strychnia. After consulting another phy- 
sician later he ordered methylblue, three 
or four times daily 0, 2 grm. On the 
second day there was difficulty of urination 
and vomiting; notwithstanding this he 
continued taking the medicine. In the fol- 
lowing few days these symptoms increased; 
urination became more painful accom- 
pained by some bleeding. After six days 
the treatment was stopped and the symp- 
toms of poisoning disappeared in a few 
days. — {Wein. Aerztl. Centr.-Anz.) 



The Treatment of Tetanus. 

Verneuil believes that the practice of 
Berger of amputating the affected member 
becomes useful in a relatively small number 
of cases since the results are not certain 
and the most favorable time for operation 
is not always known ; and lastly, that the 
excitement preceding the amputation, as 
also the administration of anaesthetics, may 
produce a fatal attack of tetanus. Ver- 
neuil in order to support this statement 
cites six cases in which amputation re- 
sulted unfavorably. Among these, three 
in which the operation was performed be- 



January 14, 1893. Abstracts. 



67 



fore a distinct attack of tetanus had 
set in. Chauvel also regards ampu- 
tation as a questionable treatment for 
tetanus. 

Vaillard could never cure artificially 
induced tetanus in an animal by amputa- 
tion. Of greater importance is the rigor- 
ous antisepsis of the wound, since the in- 
vestigations of Vincent and Vaillard have 
proven that the microbe is only active 
when in contact with other septic microbe 
(Staphylococcus and Streptococcus.) 

Trasbot called attention to the fact that 
the prognosis of tetanus in the horse, is 
more favorable if its duration extends 



over a period of two weeks. It has also 
been noticed that chronic tetanus in the 
human being is more benign than the 
acute. For that reason greater import- 
ance must be placed upon therapeutic 
treatment. 

Labanc declares that the results which 
Nocard has attained with antitoxin in 
chronic tetanus would have been healed as 
well without it. He considers the in- 
jections injurious, for the reason that 
antitoxin produces, like all other toxins, 
an exacerbation of the disease with fever 
which may induce a return of the tetanus 
symptoms. — (Bull. Med.) 



ABSTRACTS. 

CORRECT GYMNASTIC POSITIONS. 



Prof. Hans Ballin, (The Annals of Hy- 
giene, December 1892,) says: 

It is one of the main requirements in 
gymnastic work that a position should be 
correct. A carelessly executed exercise is 
of little or no value and leads often to 
the contrary of what is aimed at. He 
who practices gymnastics unsystematically, 
or he who teaches with a point in view 
to attain certain exercises and feats inde- 
pendently of position and posture of the 
whole body, gives evidence that he has 
not conceived the right spirit of physical 
culture. 

We meet, however, with the fact that 
many gymnasts who exercise at random in 
the gymnasium or at home, or indulge in 
some manly sport, pay little or no atten- 
tion to the execution of the movement as 
long as they have carried their point. 
They will jump and are proud when they 
can clear the rope at sixty inches, and they 
care very little that they did so in the most 
ungraceful manner. They will perform a 
giant swing on the horizontal bar, having 
their feet wide apart, keeping their body 
flabby and without any vigor and attitude, 
which does but little to develop muscular 
control. Now there may be some who 
claim that it matters very little how a man 
jumps as long as he exercises his body, 
and if he ever succeeds in jumping to an 
enormous height, he will be nevertheless 
the champion jumper. A man who will 
dare and accomplish the giant swing, will 
undoubtedly be considered by his comrades 
a daring fellow, who outdoes them com- 
pletely,; 



This is all true, they will be the boys 
who will find their admirers. But physi- 
cal exercise aims at more than to become 
a champion of feats; it must educate the 
body so it will be the servant of its supreme 
master — the mind ; and, f uthermore, must 
develope the human form symmetrically. 
This can only be attained by paying strict 
attention to the position and carriage of 
the whole body while performing physical 
work. An exercise which requires princi- 
pally the action of the muscles of the legs 
is of little or no account when the trunk 
and arms are in an uninteresting and care- 
less posture. 

Experience teaches us that it takes a 
long and tedious course of practice for a 
person to become master of all groups of 
muscles in order that he will he enabled 
to move them at instant command. Com- 
plex motions make it still more difficult 
for co-ordinate action. 

An untrained gymnast will lay all stress 
on tne main features of the exercise, and 
having accomplished this is unconscious 
of the appearance and correct execution. 
A boy who tries for the first time to 
climb a ladder, going hand-over-hand on 
the underside of it, will sprawl with his 
legs like a frog out of water. 

It can often be proven that these cham- 
pions of some athletic or gymnastic sport 
act surprisingly and clumsily when they 
try for the first time to execute some 
simple calisthenic movement. An exer- 
cise correctly taken must at all times be 
an exercise of the whole body; there is 
somewhere an obstruction, which must be 



68 



Abstracts. 



Vol. lxviii 



overcome by practice. These hindrances 
to the performance of an exercise indicate 
the probability that the teacher has ad- 
vanced too rapidly or unmethodically. 
The method must aim to conduct the 
scholars through the consciousness of 
bodily evolution by practice to the uncon- 
scious action. The more a person is 
lacking control over his muscular system, 
the more is he liable to bring into action, 
unnecessarily, those muscles which it is 
easiest for him to govern. If he, there- 



fore, had to exercise with his legs, and 
has better command over the muscles of 
the arm. they will do the unnecessary move- 
ments, which make a person's actions 
awkward in appearance. This awkward- 
ness is most effectually fought by laying 
stress on the carriage and posture of the 
whole body, thus recognizing the truism 
that the whole muscular system is an un- 
broken tissue, one muscle is closely allied 
to the neighboring one, and all are 
supplied from a common nerve-centre. 



CLUB FOOT. 



Dr. Ececkel, in the Australian Medical 
Journal for November, 1892, in relating 
some surgical experiences at the National 
Orthopaedic Hospital, London, says that 
the traditional treatment for club foot is 
divided into so many stages, generally 
only two. Say a baby is brought into the 
hospital with talipes equino varus of long 
standing origin. Here the stages in the 
treatment will be two — the first, the re- 
moval of the varus, the second, that of 
the equinus. Say a case is complicated 
by what is called plantar varus, that is, 
contraction of certain portions of the 
plantar fascia, and of the long calcaneo- 
cuboid ligament. Here, the first stage 
will be the removal of this deformity; the 
second, the removal of the varus due to 
the shortening of the tibialis anticus or 
posticus, or both; the third, that of the 
equinus. This dividing the treatment 
into stages simplifies matters wonderfully, 
and ensure good results in the end. It 
rests too on a scientific basis, as well as a 
practical one. 

As operative measures in true ortho- 
paedic surgery consist only in the subcu- 
taneous division of tendons, fasciae and 
ligaments, they may be said to play but a 
small part in the treatment, though often, 
of course, their role is important enough. 
The main treatment, the backbone of the 
curative procedure, is unquestionably the 
working or manipulating of the affected 
part after operation, or even without it. 

Well, we will suppose now that a mother 
brings her child, say but a few months 
old, with a congenital talipes equino 
varus. The first point is to ascertain 
whether the varus will require operation, 
that is, division of the tibialis for its re- 



moval. This is very easily done, nothing 
more easy in the work. You simply try 
with the hands whether you can force the 
baby's foot straight, that is, into a posi- 
tion free from varus. If you can, no oper- 
ation will be required ; if you cannot, you 
will have to divide the tibialis, one or 
both. For if you are able at the first 
interview to overcome the varus with the 
strength of your hands, it is an absolute 
certainty that working will remove the de- 
formity. This is a grand axiom in or- 
thopaedic surgery, a very grand axiom. 

Whatever improvement you can effect 
by manipulation for a few seconds, will 
become permanent by repeated and pro- 
longed manipulation. We will suppose 
now that in the baby's case just men- 
tioned, you find yourself to overcome the 
varus by your hands, the baby will then 
have to attend daily at the hospital to have 
its varus worked out by the nurse for a 
week or two, the mother of course bring- 
ing the child and receiving her lesson as 
to the manipulation which she will have 
to continue at home so soon as she gives 
the nurse proof of proficiency. You will 
see how excellently this plan works. It is 
naturally a great bother for the mother 
to bring her baby daily to the hospital, es- 
pecially if she lives far off. She will 
therefore exert herself to the utmost to 
learn her lesson in the shortest possible 
time. The nurse on the other hand, 
knows that at the first visit to the surgeon 
after the mother is officiating as worker, 
she will be put through her paces, that is, 
made to work her baby's foot in his pres- 
ence and before his eyes. Nurses, as you 
are all aware, do not like snubs, and some- 
thing more than a snub to the nurse would 



January 14, 1893. 



Abstracts. 



69 



follow a mother's inefficiency in the work- 
ing department. Is it difficult to work 
out the varus from a baby's foot? No, 
certainly not. You grasp your fixed 
point, or rather the point you mean to fix 
(the heel) firmly with your left hand ; with 
your right you lay hold of the lower end 
of the foot about opposite the heads of the 
metatarsal bones, and then give a series of 
jerks outwards, that is, in the opposite di- 



rection to which the varus tends. Of 
course, an experienced worker will make 
much more headway than a beginner as to 
result, still a baby's foot is so small, the 
resistance to be overcome is so compara- 
tively slight, that mothers, unless indeed 
they should happen to be the very greatest 
of geese, can manage to work out this de- 
formity in from a fortnight to five 
weeks. 



THE STORY OF THE INSANE. 



Dr. Wells, in an inaugural address de- 
livered before the Minnesota Academy of 
Medicine, Nov. 2, 1892, says in part: "In 
the light of what has been and now is, no 
state will ever permit its insane poor to 
be remanded to the mercies of the poor 
house. A generous and enlightened policy 
alone becomes the dignity and honor of 
every state in its provision for the insane. 
Their numbers are rapidly accumulating, 
and in no other way can their pressing 
needs and those of common humanity be 
satisfied. They are the most helpless and 
defenseless of all God's creatures, and the 
most dependent upon those whose reason 
has been spared and without which life is 
nothing worth. The insane are not only 
the wards of the State but above all of the 
medical profession. Through their long 
wanderings has the medical profession 
been to them a cloud by day and a pillar 
of fire by night. Before the influence of 



the new pathology prejudice and super- 
stitions have faded away. Ever their de- 
fenders they have stood inflexible between 
them and the injustice of courts and juries 
and saved them from the hangman's 
knot. 

One hundred years ago five hundred in- 
sane were chained in a single asylum 
under the lash of cruel keepers and visited 
twice a week by an apothecary. Now is 
our triumph complete as we behold the in- 
sane throughout the world in perfect 
trust, committed to our care. The mis- 
sion of the medical profession has ever 
been and is to be the benefaction of man- 
kind, and we may be justly proud of the 
part we have borne in this great and en- 
during work of reform in the affairs of the 
insane, for there exists no grander monu- 
ment to the world's enlightenment and 
progress than the redemption of the in- 
sane from their centuries of bondage." 



EXTRA-UTERINE PREGNANCY. 



At a meeting of the Gynecological Con- 
gress, at Brussels, September 16, 1892, 
( The Provincial MedicalJournal, October, 
1892), A. Martin, of Berlin, read a paper 
on this subject. His conclusions were: 
1. The etiology of extra-uterine preg- 
nancy remained, to the present day, veiled 
in the deepest obscurity. Certain hypo- 
theses already advanced only explained 
isolated cases in a manner which did not 
defy criticism. The question could not 
be settled until the physiology of impreg- 
nation was better understood. 2. Most 
frequently the ovum was implanted in the 
tube. Ovarian attachment was less rare 
than recently supposed. Abdominal in- 
sertion of the ovum remained doubtful. 



3. The diagnosis of ectopic gestation was 
a diagnosis of probability, except in cases 
where we could observe the development 
of the foetal sac outside the uterine cavity, 
or the development of an intra- uterine 
decidua without any distinguishable cho- 
rion, or when we discovered the foetus 
itself. 4. The evolutions of extra-uterine 
pregnancy rarely ended in retrograde 
metamorphosis (lithopaedion mummifica- 
tion) without any intervening accident. 
As a rule, the death of the ovum occurred 
through hemorrhage into the foetal sac, 
or into the ovum itself. The blood es- 
caped into the abdominal cavity, either out 
of the ostium of the tube (tubal abortion, 
properly so called), or by rupture of the 



70 



Abstracts. 



Vol. lxviii 



tube, in its continuity, into the peritoneal 
cavity or broad ligament. The hemor- 
rhage only ceased in exceptional cases. 
In most instances death occurred either 
from anaemia or from a peritonitis, the 
precise nature of which remained obscure. 
Ectopic gestation should always be reck- 
oned as a dangerous neoplasm, and treated 
accordingly. Cases of development to 
term were so rare that to respect the 
interests of the child was to neglect 



totally those of the mother. 6. Conse- 
quently, it would appear that operative 
interference, undertaken as soon as pos- 
sible, was the right course in all forms of 
ectopic gestation. The foetal sac should 
be extirpated if possible. Treatment by 
hypdermatic injections of morphine 
cured very slowly. Treatment by elec- 
tricity could not yet be rated at its true 
value, as hitherto recorded observations on 
this method were not above criticism. 



A CLINICAL STUDY OF GLANDEES IN THE HOESE. 



Discussing this disease, Dr. W. H. 
Daly says (Med. Record) : — In the teach- 
ings of the books, the names glanders and 
farcy are synonymous, but with the usual 
loose use of terms by the more ignorant 
- and would be veterinarians these names 
are applied to two different phases of 
glanders, with the implication that they 
are two different diseases. That form of 
glanders where the nasal discharge is most 
prominent is spoken of commonly as 
glanders ; the term farcy is used to desig- 
nate the other form, where the disease dis- 
plays lumps in the line of the lymphatics, 
along the belly and insides of the thighs, 
along the neck and elsewhere, varying 
from the size of a hickory-nut to that of a 
small apple, together with oedema of the 
legs and stiffness of the joints; later, the 
nodular lymphatics, or so-called farcy buds, 
break down and ulcerate; this form is 
spoken of as farcy, but it is all the same 
glanders, as syphilis that attacks the glands 
is none the less syphilis. 

The nasal discharge in glanders is not 
necessarily offensive, and in most of the 
cases I have seen not at all so. When the 
animals are kept as clean as possible, 
moreover, the nasal discharge is not neces- 
sarily purulent, but may be of a starchy 
character, and may be chiefly from one 
naris. 

The disease may lurk and be masked in 
the system of a horse for many months, 
and the only significant or apparent symp- 
tom may be a slight and inodorous dis- 
charge from one naris on driving the ani- 
mal. 

The horse may be far advanced in the 
disease, and with the discharge consider- 
able, when the amount he may blow from 
his nose in driving is taken into account, 
e t so far as his apparent activity, spirits. 



and appetite are concerned nothing un- 
usual may seem wrong, other than the 
evidence of a slight cold, or epizootic, 
with concomitant or following loss of flesh. 

The disease has been known to have ap- 
parently disappeared in a given animal, 
the usual discharge to disappear, flesh re- 
turn, nodular lymphatics or farcy buds to 
disappear by absorption, and later, from 
overwork or exposure to cold, the disease 
may return and pursue a fatal course. 

That glanders is highly contagious, both 
to horses and the human being, there can 
be no doubt ; yet in the stable of a friend, 
some time ago, two carriage horses were 
affected with glanders, while a third horse, 
that occupied a stall between the diseased 
horses and was in constant touch with 
them and drinking from the same buck- 
ets, was not affected, and is yet in good 
health. The glandered horses were de- 
stroyed. 

While inspecting the nares of one of my 
equine patients, after using the nasal 
douche on him, I had on two occasions 
the misfortune to receive some of the 
mucous blown by the horse from his nares 
into my eyes and about my face. A care- 
ful washing and disinfection was at once 
resorted to, without any untoward event 
following. 

I give these points as of some practical 
value, to counteract the vague and foolish 
terror that is inspired by the very name 
or suspected existence of glanders. 

Let me give you a clinical picture of a 
typical case. 

Horse twelve years old, fifteen hands 
high, weight probably eleven hundred 
pounds, dark brown, cob build, very high 
spirited, and of high intelligence and 
breeding — an animal of rare qualities and 
great endurance. This horse had for some 



January 14, 1893. Abstracts. 



71 



months a short hacking cough, that I joc- 
ularly denominated an old man's cough. 
He also had for several months a starchy 
discharge from one naris after being- 
driven. 

About January, 1892, we had an en- 
demic of la grippe in the human popula- 
tion of Pittsburg, but there was no un- 
usual amount of sickness among horses. 
This patient was not in good condition, 
however, and was losing flesh, but was 
spirited and active. One cold day in 
January, I rode him under saddle to the 
West Penn Hospital and back, a distance 
of six miles. The horse was spirited and 
anxious to go, and I indulged him, bring- 
ing him back rather warm, and instead 
of rubbing him dry, as I directed, the 
groom let him stand in a draught, while 
he turned the hose on his legs to wash the 
mud off:, and then put him in his stall 
without a blanket, and without rubbing 
his legs dry. The next day the horse 
seemed excited and nervous, but not 
otherwise the worse for his ill care and 
treatment. A few days later he exhibited 
further evidence of cold; nose running 

, copiously, cough, fever, pulse sixty, and 
limbs stiff. On examination there were 
revealed a few small lymphatic nodules 
along the belly in two direct lines back- 
ward from his forelegs ; also some nodules 
along the crease in the neck above the 
windpipe. Yet the horse ate well and 
seemed to have usual good spirits; the 
nasal discharge was inodorous, but copious 
from the left naris, the mucous membrane 
of which was swollen, turgid, and of a 
dark pink hue, but there were no chancres 
on it; the mucous was now tinged with 
blood. This was about the eighth day 
after the severe ride and the maltreat- 
ment by means of the cold water and ex- 

; posure. 

The medical treatment at this time con- 
sisted of hot bran-mashes, with saltpetre, 
quinine, carbonate of ammonia internally ; 
antiseptic nasal douch, followed by iodo- 
form insufflations twice daily. There was 
little change in this condition for six 
weeks, when the legs began to be cedemat- 
ous, and there was lameness, especially in 
the left hind leg, which was increased to 
twice the natural size by oedema. The 
farcy buds were now firm and hard, and 
as large as walnuts along the belly line 

| and the nasal mucous membrane was 
swollen, and small, punched-out, chancre- 



like sores appeared in the left naris ; the. 
discharge was lumpy and thick, but in- 
odorous, though very considerable, and 
the box stall was spattered all about each 
morning with bloody mucous of a gelatin- 
ous character, and very elastic and ad- 
herent to whatever it attached itself. 

A few days later after the douche there 
was a copious and alarming hemorrhage of 
venous blood, which was arrested by ele- 
vating and tying the patient's head high 
up. In a week later the chancrous sores 
in the left naris were more numerous and 
quite characteristic of glanders ; in fact, all 
the salient features of the disease were 
now present in undoubted character. The 
patient's appetite was normal, and the 
spirits were fair, though the emaciation 
was pitiful to behold. There was some 
arrest of the urinary secretion for a day or 
two, which was restored by the exhibition 
of rosin and saltpetre. The administra- 
tion of arsenic, quinine, and iron was substi- 
tuted for the other medicines, the cough 
and fever having abated; the copious nasal 
hemorrhage had occurred several times in 
the past week; once the amount was over 
two quarts, and was only arrested by 
a hot solution of alum, used as nasal 
douche. 

Several of the lymphatics in the throat 
and neck were now in the eighth week 
about the size of a small apple, hard and 
well denned but not tender to pressure ; 
the left nostril was enormously swollen, 
and studded with glanderous chancres 
that had sharp edges and gray bottoms 
resembling the true chancre as seen 
in primary syphilis; there was no 
odor that could be considered offensive, 
but the patient was kept as clean as pos- 
sible, and great care was observed in every 
way. 

I now gave arsenic, iron, and quinine in 
large doses, estimated as though I was 
treating a twelve or thirteen hundred 
pound man, and after a week further 
there was an abatement of the nasopharyn- 
geal symptoms, and the discharge became 
more distinctly purulent; the animal 
seemed better, and his coat, which had 
never stared or become rough but merely 
dull, looked better and somewhat glossy ; 
his eyes, which for a few days previously 
were listless, were brighter. 

Now, having had a full and very com- 
plete opportunity to study the disease in 
all its phases, so as to be able to recognize 



72 



Abstracts. 



Vol. lxviii 



it again, even in its earlier stages, I de- 
cided, although the animal was now im- 
proving, to destroy him, as I was obliged 
to absent myself from home, and there 
was rumored danger of the authorities pro- 
ceeding against me. I accordingly had 
the horse shot. The post-mortem re- 
vealed extensive chancres of the nasal 
mucous membrane, from the size of a ten 
cent piece to the size of a silver dollar; 
the bones of the nose were denuded, and 
yet, at the bottom of several of the chancres 
repair had already begun on the edges of 
some of the sores. 

Now as to prophylaxis. Complete isola- 
tion should always be resorted to, and if 
it is summer, the patient is better in an 
out enclosure or box-stall completely iso- 
lated. 

For disinfection of premises after gland- 
ers, if the structure is too valuable to burn, 
first scrape all the wood where discharges 
have been lodged by being blown from the 
patient's nose; burn these, then wash all 
down with a rough broom and a solution 
of sulphate of iron (two pounds to one- 
half gallon of water). After this close 
the place tightly and burn sulphur in it 
for several hours. After this whitewash 
with a solution of fresh burnt lime, with a 
pint of crude carbolic acid, and a pound 
of sulphate of iron to the gallon of wash, 
flushiug all crevices and corners. If this 
is done thoroughly there will be little or 
no danger to animals who occupy the 
premises subsequently , 

Soak the blankets, if valuable, in a solu- 
tion of corrosive sublimate, 1 to 500 and 
afterwards wash and boil them. Curry- 
combs, brushes, and other tools should be 
scrubbed in hot water and soaked in a 
solution of corrosive sublimate 1 to 500. 
Harness can be washed in rather warm 
water, then rinsed in a sublimate solution 
and afterward rinsed in clear water and 
cleaned with a carbolic or mercury soap 
for a few times ; care should be taken to 
eliminate from all the corners about the 
buckles and keepers any dandruff from the 
diseased animal. 

The all-important question in glanders 
is to be able to recognize the early mani- 
festations of the disease. This is exceed- 
ingly difficult, as the conditions are so 
masked, but from my observation I should 
say, where an animal has certainly been 
exposed to contagion take the best of care 
of him in every way, and observe the 



strictest cleanliness, and if later on you 
observe a persistent but very slight dis- 
charge from one or both nares, and some 
even slight lymphatic nodules along the 
belly-line of lympatics, from the size of a 
coffee-grain to a hickory-nut, these are 
the so-called "farcy buds," which when 
once felt can never be mistaken. If there 
is in addition a slight fever, put your 
horse on good alterative tonics and isolate 
him, but do not ruthlessly destroy him. 

As an experiment I expose a young- 
horse to the contagion, and at a time when 
he was suffering from colt distemper. The 
glanderous disease went on to development 
of farcy buds, slight nasal discharge, and 
temporary loss of appetite. The symp- 
toms under the above alterative 
treatment all disappeared in less than two 
months, and the horse was in an improved 
condition 1 and although he is now receiv- 
ing no treatment is, beyond doubt in my 
mind, safely in a sure convalescence, bar- 
ring no accidents that will deteriorate his 
general health. 

As to character of the disease I am of 
the opinion it is of a specific character, 
that is, contagions through its peculiar 
bacillus malleis, and that it is to a certain 
unascertained degree curable if taken 
early and properly isolated. 

But I repeat herein lies the difficulty, 
viz., an early recognition of the disease. 
I would not by any means advise the pur- 
chase of a horse who upon a little active 
exercise runs a little starchy mucous from 
the naris or nares and has some hard 
nodular kernals like a pea or chestnut in 
the cellular tissues under the skin along 
the belly in a line with the forelegs ; these 
are among the earlist objective constitu- 
tional symptoms, and I regret to say when 
present are often so masked as to escape 
notice of any other than an expert ob- 
server. 

This is a clinical picture of glanders as 
I have personally observed it, and without 
regard to the teaching of the books, and I 
have given it to you, hoping that it may 
interest you not only in preventing the 
disease in those noblest of the lower 
animals, but also in the human being, 
who is so liable to be attacked by means to 
contagion. 



1. Three months later this young horse is in fine 
condition and, so far as I can discover, in perfect 
health. 



January 14, 1893. Library Table. 73 

THE LIBRARY TABLE. 



Notes on the Newer Remedies and their Therapeutic 
Application* and Modes of Administration. By David 
Cerna, M. i) , Ph. D. Demonstrator of Physiology 
in the Medical Department of the University of 
Texas, etc., etc. Philadelphia, W. B. Saunders, 
913 Walnut Street, 1893. Price $1.25. 
The author has endeavored to furnish the 
practitioner and student, in as brief a manner 
as possible, the salient points in the employ- 
ment of the newer drugs in the treatment of 
disease. Such of the drugs as are not yet fully 
studied therapeutically, are given only a pass- 
ing notice. The book will be useful to the 
student or practitioner who, without neglect- 
ing important matters, can keep abreast of 
the times in the science and art of modern 
therapeutics. 

Acne and Alopecia. By L. Duncan Bulkley, A. M., 
M. D., Professor of Diseases of the Skin, New York 
Post- Graduate Medical "School; Physician to the 
New York Skin and Cancer Hospital, etc. Published 
by Geo. S. Davis, Medical Publisher, Detroit, Mich. 
Price, postpaid : Paper, 25 cents; cloth, 50 cents. 

The author presents these diseases in a 
clear, concise manner. No attempt is made 
to exhaust the subject, nor are references 
made to authorities. The desire has been to 
present the conditions as they appear to one 
daily engaged in relieving them. The 
author's reputation as a practitioner, is suffi- 
cient guarantee of the book's usefulness. 

Gonorrhoea and Urethritis. G. Prank Lydston, M. D. 
George S. Davis, Detroit, 1892. 

The author of this valuable little book has 
succeeded in getting a vast amount of inform- 
ation in its pages. His views as regards the 
pathology and treatment of gonorrhoea are 
distinct and practical. He does not advocate 
the abortive plan of treatment, claiming it a 
relic of by-gone days. 

The work abounds in useful suggestions. 
To the physician who desires knowledge in 
the treatment of Genito Urinary Diseases 
this little book will be a welcome mentor. 

The Students' Quiz Series. Edited by Bern B. Gallau- 
det, M. D., Demonstrator of Surgery, Gollege of Phy- 
sicians and Surgeons, New York. This new series of 
Manuals in form of question and answer enjoys the 
unique advantage of issue under careful editorial ar- 
rangement and supervision. The Editor, himself an 
experienced practitioner and teacher, has assigned 
the various volumes to well-known specialists and in- 
structors in New York. The thirteen volumes cover 
the subjects essential to a thorough knowledge of 
medical science and art, and they may be trusted as 
authoritative and abreast of the times. They are of 
value not only to students and teachers, but to prac- 
titioners who may desire to recall details for instant 
use. 

The large utility of this series therefore assures an 
enormous sale and justifies a very low price in pro- 
portion to intrinsic value. 
Anatomy, Brockway, F. J.; Physiology, Manning, F. A.; 
Chemistry and Physics, S truth ers, J.; Histology, Pa th- 
ology and Bacteriology, Beach, B. S.; Materia Medico 
and Therapeutics, Warner, L. F.; Practice of Medicine, 
Doubleday, E. T.; Surgery, Sands, R. A.; Genito — 
Urinary and Venereal Diseases, Chetwood, C. A.; 
Disease of the Skin, Ransom, C. C; Diseases of the 
Eye, Ear, Throat and Nose, Miller, F. E.; Obstetrics, 
Jloyt, C, W.; Gynecology, Bratenahl, G. W.; Diseases 
of Children, Rhodes, C. A. 



Bo far as works of this nature can be of use 
these compends answer the purpose of their 
publication. Lea Bros. & Co. being the pub- 
lishers is sufficient guarantee of the superior- 
ity in this class of medical books. 



KECENTEY RECEIVED. 

Fermentation, Infection and Immunity. A new theory of 
these Processes. By J. W. McLaughlin, M. D., Aus- 
tin, Texas, 1892. Price 2.50. 



Hand-book of Massage. By Emil Kleen, M. D., Ph. D., 
authorized translation from the Swedish, by Edward 
Mussey Hartwell, M. D., Ph. D. Philadelphia: P. 
Blakiston, Son & Co., 1012 Walnut Street, 1892. 
Price $2.75. 



A Manual of Clinical Ophthalmology. By Howard F. 
Hansell. M. D., and James H. Bell, M. D. Philadel- 
phia: P. Blakiston, Son & Co., 1012 Walnut Street, 
1892. Price $1.75. 



A Hand-book of the Diseases of the Eyes and Their 
Treatment. By Henry Swanger, A. M., M. B., F. R. 
C. S. I. Fourth edition. Philadelphia: P. Blakis- 
ton, Son & Co., 1012 Walnut Street, 1892. Price 
$3.00. 

Transactions of the Homeopathic Medical Society of 
Potnsylvania, 1892. 



NOTES. 

Dr. Nicholas Senn, of Chicago, is now preparing a 
" Syllabus of Lectures on the Practice of Surgery " 
arranged in conformity with the " American Text- 
Book of Surgery, which will be a valuable aid to all 
who have this great book. 



Moullin's Text-Book on Surgery was first published in 
April, 1891. So favorable was its reception by the 
medical profession and press that in a little over 
twelve months it was recommended at more than 
twenty medical Schools, and the large edition tha t had 
been prepared was exhausted. So much for past his- 
tory. 

Early last summer Blakiston, Son <fc Co., were 
fortunate in securing the services of Dr. John B. 
Hamilton, formerly Surgeon-General of the Marine 
Hospital Service, now Professor of Surgery at Rush 
Medical College, Chicago, as editor for a new edition. 
He has now almost completed his work, and within 
a short time they expect to place before you the 
book generally revised so as to represent Surgery as 
it is to-day, with a number of new and beautifully 
colored illustrations printed in with the text. 

" Our claim that Moullin's Surgery is the best 
text-book for the student, and general work of refer- 
ence for the practitioner is based upon the reviews 
of a large number of journals that have pronounced 
it eminently practical, and upon the fact that so 
many teachers have seen fit to recommend it. But 
beyond this we may say that broad principles are 
stated in a clear, authoritative manner, that the 
relative value of the different subjects has been care- 
fully considered, and that about the whole there is an 
air of responsibility that renders plain the fact that 
the author knows whereof he speaks, not only from 
his own experience, but from an acquaintance with 
American and foreign literature. There is also a 
uniform ty of style, an elegance of diction, that at- 
tracts and interests the reader, while it makes plain 
the subject under discussion." 



74 



Current Literature. 



Vol. Ixviii 



Public Opinion, the eclectic weekly, of Washington, 
D. C, which has made a feature of offering liberal 
cash prizes for the best essays on prominent topics, 
has ju>t announced three casb prizes of $150, $100, 
and $50, respectively, for the best three essays upon 
the question " What, if any, changes in the present 
immigration laws are expedient?" The contest is 
open to any one and full particulars may be had by 
addressing Public Opinion, Washington, D. C. 



The "American Text-Book of Surgery," edited by Pro- 
fessors Keen and White, of Philadelphia, is pro- 
nouuced a success. It has been adopted as a "Text- 
Book " by leading Medical Colleges and Universi- 
ties. Nearly five thousand copies have been placed 
in physician's libraries, and every indication points 
to a sale of at least as many copies more in the next 
six months. 



CURRENT LITERATURE REVIEWED. 



THE ANNALS OF HYGIENE. 

The opening article of December's issue is 
Prof. Ballin's on ''Correct Gymnastic Posi- 
tions," of which we give fuller note else- 
where. Under the title of "Hunting Health 
and Bears " Dr. Reed, of Ohio, gives quite a 
lengthy description of the hygienic advan- 
tages obtained by those who, weary and worn 
out by the duties of an exacting practice, or 
from the daily wear and care of a humdrum 
business life," have their vitality exhausted 
and seek to regain it by spending a vacation 
in the Rocky Mountains " hunting health and 
bears." 

"Secrets of Health " by Dr. Parker and 
"Sanitary Day " by Dr. J. F. Edwards about 
finishes this month's issue. 



THE JOURNAL OF NERVOUS AND MENTAL 
DISEASES. 

The only article of any importance in De- 
cember's number is one on " The Equitable 
Responsibility of Inebriety " by Dr. Wright. 
Dr. E. P. Hurd has a translation of Professor 
Charcot's paper "Vibratory Therapeutics" 
— the application of rapid and continuous vi- 
brations to the treatment of certain diseases 
of the nervous system. These two articles 
together with Dr. Field's paper on " Othe- 
matoma" comprises all that is of any import- 
ance in this month's issue. 



ARCHIVES OF PEDIATRICS. 

In looking over the list of collaborators, forty- 
eight in number, which is given a prominent 
place and which contains the names of 
men who have devoted a life time to the sub- 
ject of Pediatrics, and then turning to the 
table of contents and glancing over the list 
of original communications one is amazed at 
the meager exhibition-— four papers, three 
read before the American Pediatric Society 
last May, the other read before the American 
Orthopaedic Association in September. 



COLLEGE AND CLINICAL RECORD. 

The Dec. ' ' Record" contains only two papers 
of any note. " The Puerperal Sepsis," by 
Dr. El E. Montgomery, and "Urethral Irri- 
tation" by Dr. Mary jacobi. We trust that 
this journal which has had an existence of 
thirteen years will commence its next year 
by putting its table of contents in a place 
that its subscribers can find, without having 
first to read its articles and advertisements. 



THE PHILADELPHIA POLYCLINIC. 

The "Polyclinic" announces in its December 
number, that beginning with January, 1893, 
it will be issued monthly instead of quarterly 
as heretofore. 

Dr. Crozier Griffith has an interesting lec- 
ture on "Diagnosis of the more frequent 
Organic Heart Murmurs." "The Prophy- 
lectic and Palliative Treatment of Fistula in 
Ano" by Dr. Lewis Adler, Jr., is the more 
important paper. 



INTERNATIONAL MEDICAL MAGAZINE. 

The December issue appears with eleven 
original papers, four of which were read last 
June before the American Climatological As- 
sociation. Dr. Eli Long has a paper on 
" Physiology of the Respiratory and Circula- 
tory Changes at Birth as related to Asphyxia 
and its Treatment." A particularly good 
article is a Clinical Lecture of Dr. Hulke, of 
Middlesex Hospital, London, on "Aneurism." 
Possibly mention should be made of Dr. 
Dewey's "Study of Insanity following 
the Keely treatment for Inebriety." The 
doctor is inclined to think that this treat- 
ment consists of a medication of well-known 
tonics and perhaps cathartics combined with 
some narcotic or mydriatic drug, probably 
atropine, together with the powerful influ- 
ence, mental, with which the patient is sur- 
rounded. Dr. Keely to the contrary notwith- 
standing denies in toto the uses of narcotics. 



UNIVERSITY MEDICAL MAGAZINE. 

Dr. Daland's article "A Clinical Study of 
Eleven Cases of Asiatic Cholera treated by 
Hypodermoclysis and Enteroclysis," is given 
first place in January's number. This paper 
is the result of a very careful study of the 
clinical history and treatment of Asiatic 
Cholera. These observations were made at 
the Swinburne Island Hospital in New York 
Bay last September. 

" Mydriatics in Ophthalmology," by Dr. 
Risley, is given second place. In considering 
these drugs the doctor states that it is, first of 
all, important that the solutions of the salts 
of the alkaloids in use should be bland, since 
any irritation of the tissues is especially 
harmful and directly opposed to the pur- 
poses for which the drug is usually employed. 

Dr. Sinkler's paper "Insanity in Early 
Childhood " completes the articles of interest 
in this number. 



January 14, 1893. 



Periscope. 



75 



PERISCOPE. 



THERAPEUTICS. 

Peroxide of Hydrogen in Gastric Dis= 
turbances. 

A. N. Iakovleff (St. Petersburg Inaugural 
Dissertation, 1892, No. 109) has made nine ex- 
periments on eight subjects, of whom some 
were suffering from chronic gastritis, some 
from nervous dyspepsia, one from cancer of 
the stomach, and one from hyperacidity of 
the gastric juice, while the eighth was 
healthy. In all but two cases the patients 
were given 4 c. c. of a three-per cent, solution 
of H 2 O z before breakfast, dinner, and supper. 
The patient with malignant disease and the 
one with hyperacidity took a two-per cent, 
solution, 4 c. c. from three to six times a day. 
The following is a summary of the results of 
these experiments: (1) Under the influence 
of H 2 2 the general acidity of the gastric 
juice and the proportion of free HC1 invari- 
ably increase. (2) The proportion of lactic 
acid always decreases, while in later stages of 
digestion the acid disappears altogether from 
the gastric contents. The phenomenon should 
be attributed to the well-known antifermenta- 
tive properties of H 2 2 . (3) The digestive 
power of the gastric juice is markedly intensi- 
fied. (4) In the case of hyperacidity (as well 
as in another similar case in the author's 
private practice) the administration of the 
peroxide was followed by a distinct aggrava- 
tion of all gastric symptoms, while in all 
others, including that of cancer, marked im- 
provement was observed, the appetite im- 
proved, the epigastric pain ceased, eructa- 
tions and vomitings decreased or entirely dis- 
appeared, the bowels became more regular, etc. 
The author further made experiments on frogs 
and dogs, his object being to elucidate the 
effects of H 2 2 on the circulation. The re- 
sults agree pretty closely with those published 
by Guttmann and Schwerin, the essential 
point being that H 2 2 is decomposed by the 
blood, and hence can give rise to gaseous 
embolism with its* consequences, such as 
dyspnea, dilatation of the cardiac cavities, 
etc. From these facts, Iakovleff concludes 
that injections of H 2 2 into the circulation 
for therapeutical purposes, as suggested by 
some authors, are absolutely inadmissible. — 
Brit, Med. Jour. 



The Simplification of Therapeutics. 

The day of a more precise, hence more 
scientific application of remedies in the man- 
agement of disease is dawning. Polypharm- 
acy is the offspring of that mysticism with 
which our forefathers were wont to surround 
themselves unconsciously. In all other 
phases of human endeavor a spirit of inquiry 
is abroad; the devout churchman even asks 
questions to-day which a few decades ago he 



would have deemed sacrilegious to entertain. 
He does not on that account lose aught of the 
true essence of religion; but he satisfies his 
reason as far as is consistent with his faith. 
We cannot marvel, therefore, if the doctor's 
clients often want to learn something of the 
agencies resorted to in combating an enemy 
supposed to reside within them. 

The multi-pharmaceutical prescriptions we 
give him are not open to his comprehension; 
indeed candor would oft compel the prescriber 
himself to acknowledge a lack of rational ap- 
preciation of the objects and aims of his medi- 
cation. 

It has come, about, therefore, that the 
latter has become more simplified. The shot- 
gun prescription of a former epoch is now 
rarely seen. The trend of teaching now is in 
the direction of the rationale of remedies. 
Thus the student becomes less slavish in his 
adherence to formula? because he understands 
better the principles underlying the action of 
their component parts. 

We may learn a valuable lesson on the Evo- 
lution of Simplified Therapeutics, and its enor- 
mous value, from the surgeon. When anti- 
septic surgery first astounded the filth-ridden 
surgical world, the minutiae of spray, gauze, 
protective, etc., seemed absolutely necessary 
to success. We discover now that poly-anti- 
sepsis is unnecessary; that the chief element 
of true antisepsis is asepsis or cleanliness. 
The scrupulous, unflinching, searching and 
skeptical cleansing of the field of operation, 
of the operator, and of the wound, proves to- 
day to be the source of the most brilliant sur- 
gical statistics. Dr. C. Schimmebusch, upon 
whom devolves the preparation of cases for 
the most renowned surgical clinic in Ger- 
many, considers " boiling water as the most 
powerful of all disinfecting agents." He 
says: Instruments are best sterilized by boil- 
ing in a one-per cent, watery solution of car- 
bonate of soda for five minutes, the soda in- 
creases the sterilizing power of boiling water, 
because it removes all fatty material and pre- 
vents rust, What is this but plain, unvar- 
nished cleanliness. While this evolution to 
the simpler, hence higher, type of treatment 
is going on in the brilliant 'field of surgery, 
let the physician draw lessons of value from 
it. May we not by simplifying medication, 
by boiling down, as it were, our formulae to 
active therapeutic entities, by eliminating 
mystical, inexplicable methods, and holding 
fast only to simple, rational, demonstrable 
therapeutic agents, do as much for internal 
disease as the surgeon has done for the palp- 
able or external. It is a consummation de- 
voutly to be wished; it must come in good 
time. In the meanwhile the sick are lan- 
guishing or dying under our ministrations. 
"Let us be up and doing." Who shall be 
the Lawson Tait of Internal Medicine? The 
man who is bold enough to combat the pre- 
judices of the most prejudiced middle class — 
the medical practitioner.— Gail. Med. J. Edit, 



76 



Periscope. 



Vol. lxviii 



Cocaine Antidotes. 

S. Mitchell (Medical Record) has found 
that while ammonia, digitalis and brandy 
will relieve the milder toxic manifestations of 
cocaine poisoning, they signally fail when 
these symptoms are superseded by severe 
precordial pain, weak and rapid pulse, sigh- 
ing respiration, borborygmus and belching of 
wind, muscular rigidity, and later paralysis 
of the whole body except the brain, which is 
unnaturally active. In such a case he used a 
large teacupful of clear coffee, and has found 
it equally efficacious on subsequent occasions. 
It can be administered cold or hot. He 
makes no mention of amylnitrite. 

Gluck (Ibid.) advocates dissolving the 
cocaine in a 3 per cent, solution of phenol. 
This, he claims, prevents the toxic effects of 
the former drug and renders the solution 
stable; as is well known, such solutions 
otherwise lose their anaesthetic effect after 
twenty-four hours. Phenol, besides, has a cer- 
tain anaesthetic power of its own, forms a super- 
ficial eschar, which prevents absorption of the 
cocaine, destroys bacteria, fungi, etc., pre- 
vents decomposition in the solution, renders 
it aseptic and wards off reactive congestion . 



The Use of Cod Liver Oil in Rheumatism. 

Cod liver oil has obtained such a definite 
reputation against tuberculous and scrofulous 
affections that we are apt to forget its virtues 
in other maladies. In the first instance, it 
was employed against chronic rheumatism, 
and gained enthusiastic opinions. I have be- 
fore me the original report in reference to this 
latter use by Dr. Bardsley, of Manchester, 
who in April, 1807, wrote that it had then for 
thirty years enjoyed a very high local reputa- 
tion. It had been much used in the Man- 
chester Infirmary by Dr. Percival and by Dr. 
Bardsley himself. The latter reports that it 
is variable in its efficacy, often in the mild 
and more common forms not doing any ap- 
preciable good. He thought it most useful in 
chronic cases in elderly persons and in women 
debilitated by parturition. He thought that 
it seldom did good unless it fattened. His 
dose was half an ounce to an ounce and a-half 
twice a day, and he found warm beer to be, 
with the laboring classes, the favorite vehicle. 
If benefit was obtained, it ought to be con- 
tinued for six or eight months. He asserts: 

" I have seen a few patients recover entirely 
by the exhibition of the oil who on their ad- 
mission into the house were unable either to 
preserve the body in an erect position, or sup- 
port its weight on the lower extremities." 
The consumption of cod liver oil in the Man- 
chest er Infirmary from 1776 to 1807 had 
averaged fifty or sixty gallons annually. It 
now amounts to four hundred gallons." The 
profusion with which new chemical remedies 
have been supplied to us of late years may, it 
is very possible, have led to the comparative 
neglect of old ones, and that, perhaps, not al- 
ways to the advantage of our patients. — Arc. 
of *8urg. 



MEDICINE 

The Disadvantages of Hot=water Bottles 

The custom which so largely prevails main- 
ly among ladies of using hot-water bottles in 
bed for the purpose of warming their feet, 
time-honored as it is, cannot after all be said 
to have had much to commend it. Indeed, 
there is a good deal more which can be urged 
against it than can be said in its favor. 
Ladies who resort to the habit, for habit it 
soon becomes in the majority of instances, 
suffer from cold feet, a condition which, it is 
needless to say, does not particularly conduce 
to the wooing of sleep. But cold feet is a 
symptom which should not be left to be dealt 
with at the end of the day; on the contrary, 
those in whom it occurs should bear in mind 
that in ordinary health the proper remedy for 
this condition' is exercise. Nothing tends 
more to cause " cold feet " than sitting about 
the house all day, or reducing the daily exer- 
cise to a minimum amount, either on account 
of laziness or feebleness of will-power for 
exertion. Some persons console themselves 
with the reflection that they were born with 
cold feet, and on these grounds hold that it was 
always intended that they should warm them 
by artificial means, thus ignoring the neces- 
sity which exists for exercise. Hot bottles, 
too, used in this way become a fertile source 
of chilblains, and, moreover, are not devoid 
of danger. We heard the other day of two 
cases in which the ladies using them were 
seriously scalded by the cork of the earthen- 
ware bottle containing the boiling water sud- 
denly popping out. This brings us to the con- 
sideration of whether hot bottles should be 
used at all, and we think the answer should 
be in the negative. The best way of warming 
cold feet at night is to clothe them with warm 
woolen socks or stockings, which may be 
slept in. By this means the temperature of 
the feet is gradually raised, and is equably 
maintained throughout the night without 
trouble or risk. Another useful plan is to 
raise the feet on a pillow about two inches 
above the knee, so as to facilitate the return 
of the blood through the veins of the limbs. — 
Med. Press. 



The Knee= jerks in Supervenosity. 

Hughlings Jackson has observed that knee- 
jerks are absent in some cases of emphysema 
with bronchitis, where the blood has become 
venous to an extreme degree. Dr. Russell, 
at his suggestion, examined the knee-jerks of 
a dog, artificially asphyxiated by clamping 
its trachea; the 'animal's knee-jerks became 
exaggerated until knee clonus was produced; 
but in the third stage of asphyxia, no reaction 
could be obtained. As asphyxia diminishes, 
and in an extreme degree annuls, the excita- 
bility of the motor cortex, it may be that the 
preliminary exaggeration of the knee-jerk ob- 
served by Dr. Russell, was owing to loss of 
cerebral control upon lumbar centres, and 
that these spinal centres succumbed later to 
the influence of supervenous blood, than did 
the controlling cerebral motor centres. When 
oxygen is given to cyanosed patients, their 



January 7, 1893. 



Periscope. 



77 



knee-jerks should be tested before and after 
the gas is administered. If successfully used, 
that is, if the patient's blood becomes well 
oxygenated, it is possible that knee-jerks ob- 
tainable before administration of the gas, may 
be elicited afterwards. If supervenosity 
causes loss of the knee-jerk, the fact. may be 
important with reference to the apoplectic 
state, and also with regard to post-epileptic 
coma. In some cases of apoplexy from cere- 
bral hemorrhage, the knee-jerks are lost, in 
others not. The author suggests investigat 
ing these points in all cases of supervenosity. 
—Brit. Med. Jour. 



The' Etiology of Acute Bright's Disease. 

Agnes Bluhm (Deutsch. Archiv. f. klin. 
Med.) has classified the causes of all cases of 
Bright's disease occuring in the Medical clinic 
at Zurich, during a period of 5] years. The 
infectious diseases are the chief cause of acute 
Bright's disease, occuring as it does after 
typhoid fever, acute exanthemata, erysipelas, 
variola, diphtheria, tonsillar angina, croup- 
ous pneumonia, acute peritonitis, and acute 
miliary tuberculosis. Among the chronic in- 
fectious diseases, tuberculosis and syphilis are 
mentioned; a number of skin diseases are also 
included. Eczema, psoriasis, tuberculosis 
cutis, and erythema nodosum. Among toxic 
causes, three cases are noted following the use 
of mercury, lead and thallin. Among the 
other causes of acute nephritis are mentioned; 
intestinal diseases, icterus, circulatory affec- 
tions, pregnancy, leukemia, and gonorrhea. 
In nine per cent, of the cases, no etiology 
could be determined. The causes of the 
chronic parenchymatous form of nephritis are 
more uncertain, but it was due in the larger 
number of cases to malaria, misuse of alcohol, 
and unhygenic conditions. Among the 
causes of genuine contracted kidney, syphilis 
was present in eleven per cent, and arterios- 
clerosis in 17.7 percent, of the cases; misuse 
of alcohol and lead were also concerned in the 
etiology of this form of nephritis. Regarding 
the development of acute nephritis after acute 
infectious diseases, it was observed that 
neither the severity nor the course of the pri- 
mary affection exerted any special influence 
on the nephritis.— Cent. f. klin. Med. 



SURGERY. 

Poultices are remedial when the "sign is 
right," but some physicians have trouble in 
discerning when it is right, and place the 
poultice on the wrong place. A poultice 
should not be applied to a recent wound un- 
less the physician wishes to interfere with 
the 4 'vis medicatrix naturae" It seems al- 
most incredible that a physician will advise 
that a crushed finger, hand or other injured 
part be poulticed, and advise this measure day 
after day; but such is the lamentable fact. 
We call attention to this poulticing of recent 
wounds in particular, because it has been our 
luck to see several cases of this form of mal- 
practice recently, and if any one who is in the 
habit of poulticing recent wounds should 



happen to see this we will be amply repaid if 
he or she will stop and consider the harm that 
will be done by so unscientific a procedure. 
If you wish heat and moisture for the relief 
of pain and congestion, immerse the part in 
hot water until the effect is accomplished. 
This will give greater satisfaction to your 
patient and do real good. ' ' The sign is right" 
for a poultice when you wish to devitalize the 
part and hasten or promote the suppurative 
process. Don't apply them to recent wounds. 
— Kansas Med. Jour. 



Treatment of Hemorrhoids. 

Mr. J. Brindley James states (Brit. Med. 
Jour.) that for some years he has been in the 
habit of treating hemorrhoids by the simple 
process of applying calomel to them with the 
finger alone, and without a single exception 
he has done so with marked success, especi- 
ally when inflammatory action was obvious 
in the hemorrhoidal mass, characterized by 
mucous discharge, and hemorrhage, accom- 
panied by a most painful sensation of weight 
in the rectal region. All these symptoms 
under this simple influence were speedily re- 
lieved, with the still more important subse- 
quent advantage of the patient's restoration 
to ease. A short time since a patient came to 
him suffering so acutely that he could neither 
sit nor walk freely, each movement of the 
body entailing excruciating pain. He has 
now seen him thoroughly enabled to pursue 
his usual occupation in happy immunity 
from these distressing symptoms'. — Ex. 



Treatment of Appendicitis.. 

Appendicitis of the perforating type may 
generally be diagnosed by symptoms of 
shock, which speedily appear after the ulcer- 
ated appendix has developed. An anxious 
countenance; blue finger-tips; nose and ears 
cold; pulse and respiration excited, rapid or 
sighing, and out of relation with the tempera- 
ture; tenderness in the abdomen; pain in the 
abdomen, generally in the neighborhood of 
the right inguinal region, are pretty reliable 
data for diagnosis of perforating appendicitis. 
When these symptoms occur in a case, there 
is no alternative but to open the peritoneal 
cavity and remove the offending appendix. 
But in another type of appendicitis, in which 
there are none of the symptoms of shock 
above described, except tenderness in the 
inguinal region with more or less rise of tem- 
perature, a surgeon may wait until he is 
satisfied that suppuration exists, and then 
incision should be made and the abscess 
evacuated. If the appendix can be readily 
reached and separated from the surrounding- 
structure without breaking through the 
neighboring adhesions of the peritoneal 
cavity, it may be removed; but in the major- 
ity of cases of suppurating peritonitis in 
which there is a local abscess about the ap- 
pendix, which can be reached without per- 
forating the peritoneum, it is better to simply 
drain the cavity than to insist upon a re- 
moval of the ulcerated appendix. — Col. and 
Clin. Rec. 



78 



Periscope. 



Vol. lxviii 



Can a Septic Bullet Infect a Gunshot 
Wound. 

L. Lagarde (New York Medical Journal) 
nays: 

The vast majority of cartridges in original 
packages are sterile and free from septic 
germs. This is due to the thorough disinfec- 
tion and absolute cleanliness observed in the 
process of manufacture. 

The disinfection with heat, acids, and 
alkalies, and the rigid rule of cleanliness used 
in the process of manufacture, are employed 
to exclude grease and dirt, as the latter impair 
the keeping qualities of the powder and dis- 
turb ballistic values. 

The majority of gunshot wounds are 
aseptic, because the vast majority of the pro- 
jectiles inflicting them are either sterile or free 
from aseptic germs. 

Cartridges out of original packages show 
micro-organisms upon them, and these are 
not entirely, if at all, destroyed by the act of 
firing. 

Anthrax, when applied to the projectile of 
a portable weapon, is seldom if ever entirely 
destroyed by the act of firing. 

When a gunshot wound is inflicted upon a 
susceptible animal by a projectile infected 
with anthrax, the animal becomes infected 
with anthrax and in the vast majority of in- 
stances dies from said infection. 

The heat developed by the act of firing is 
not sufficient to destroy all the organic mat- 
ter on a projectile, the cherished notion of 
three centuries and more to the contrary not- 
withstanding. 

The results justify the assumption that a 
septic bullet can infect a gunshot wound. 



OBSTETRICS. 

Prevention and Cure of Puerperal Sepsis. 

In a paper on this subject (Cin. Med. Jour.) 
Dr. W. W. Potter arrives at the following 
conclusions: 

1. Obstetric engagements once accepted 
should be faithfully fulfilled, no matter how 
awkwardly they fit. Apply the same rule of 
cleanliness to the poor and rich alike. De- 
cline service when this cannot be done. 
Human life is too precious to jeopardize it by 
slip-shod, half-hearted or indifferent service. 

2. The physician should be a model of 
cleanliness in body and clothing, and should 
insist upon the observance of similar condi- 
tions by all persons in and about the lying-in 
chamber. 

3. The delivery room, whether in hovel or 
palace, court, alley, or avenue, should be 
simple in its furniture and hangings, and be 
cleaned with soap, water, and whitewash (if 
possible to use the latter) immediately before 
occupancy by the puerpera. 

4. The delivery bed should consist of a new 
tick filled with sweet and clean straw, covered 



with a blanket, impervious dressing, and a 
folded sheet, with other covering to be allowed 
according to season. Exceptions to this 
simple bed should be as few as possible, and 
in no event should a bed be substituted that 
has been used by the sick, or that is not be- 
yond even a suspicion of infection. 

5. The patient should be especially prepared 
for delivery by baths and enemata, vaginal 
douches, and clean clothing; and labor should 
be conducted on the lines of absolute cleanli- 
ness, with few digital examinations and a 
complete delivery of the secundines. 

6. Lesions of the genital tract should receive 
careful attention; rents of the perineum 
should be repaired, and so, too, in some in- 
stances, should tears of the cervix. 

7. Antiseptic solutions containing a germi- 
cide should be used for cleaning the hands 
and instruments of the operator. Intra- 
uterine irrigation with sterilized water should 
be carefully employed after operative mid- 
wifery, either manual or instrumental. 

8. Finally, if sepsis proceeds to suppuration 
and abscess the abdomen should be opened, 
pus cavities emptied, irrigation used, and 
drainage established. If the uterus and ad- 
nexa become thoroughly infected they should 
be extirpated. 



NEWS AND MISCELLANY. 

The Medical Society of the State of Penn- 
sylvania will meet in Williamsport, May 16, 
17, 18 and 19. All who desire to read 
papers at the session must submit them by 
title and probable time needed, to Dr. H. G. 
McCormick, Chairman of the Committee of 
Arrangements, Williamsport, not later than 
March 1st. 



ARMY AND NAVY. 



FROM JANUARY 1, 1893, TO JANUARY 7,. 
1893. 

First Lieutenant Isaac P. Ware, Assistant 
Surgeon, U. S. Army, is assigned to duty at 
Fort Sill, Oklahoma Territory until further 
orders. 

The leave of absence for two weeks, on sur- 
geon's certificate of disability, granted to Cap- 
tain Adrian S. Polhemus, Assistant Surgeon, 
U. S. Army, is hereby extended fourteen (14) 
days, from December 30, 1892, on surgeon's 
certificate of disability. 

Lieut. Col. Charles H. Alden, Deputy Sur- 
geon General, U. S. A. to be Asst. Surg. 
Genl. with the rank of Colonel, Dec. 4, 1892, 
vice Heger, retired. 

Major Albert Hartsuff, Surgeon, to be 
Deputy Surg. Genl. with rank of Lieut. Col. 
Dec. 4, 1892, vice Alden, promoted. 

Capt. Louis M. Maus, Ass't. Surgeon, to be 
Surgeon, with the rank'of Major, Dec. 4, 1892, 
vice Hartsuff promoted. 



Vol. LXVIII, No. 3. 
Whole No. 1873. 



JANUARY 21, 1893 



00 per Annum 
10 Cents a Copy 



A WEEKLY JOURNAL. 



THE 



Established 1853, by S. W. Butler. M. D. 



MEDICAL AND SURGICAL 

REPORTER 



Entered as Second-Class Matter at Philadelphia P. O. 



P. O. BOX 843, PHILA, PA. 



ORIGINAL ARTICLES. 

W. F. McNutt, M. D„ M. R. C. S., Ed., etc., San Francisco. 
Five Cases of Vaginal Hysterectomy for Malignant 
Disease of the Uterus. — All Recovered 79 

CLINICAL LECTURES. 

Prof. Roswell Park. 
Talipes Fracture of Acromial End of Clavicle, Double 
Fracture of Shaft of Femur, Hare-Lip 83 

COMMUNICATIONS. 

Dr. J. E. Hayes. 

Cerebral Syphilis .86 

A. M. Cartledge, M. D. 
Sarcoma of the Breast at the age of Sixteen Years: 

Ovarian Cyst 88 

Dr. Albu, in Berlin. 
Clinical and Experimental Contribution to the Treat- 
ment with Creasote of Pulmonary Tuberculosis . . 89 

SOCIETY REPORTS. 

The Medico-Chirurgical Society of Louisville .... 90 



CORRESPONDENGE. 

Revival of " Heatonism;" Hernial Institutes and Sub- 
cutaneous Injections for Hernia 95 

EDITORIAL. 97 

TRANSLATIONS 101 

ABSTRACTS 303 

CURRENT LITERATURE 110 

PERISCOPE 

MEDICINE 114 

SURGERY 116 

NEWS AND MISCELLANY 117 

ARMY AND NAVY • . 117 



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A Perfect kaxative 



the' California Fig Syrup Company manufactured, from the 
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THE 

Medical and Surgical 
Reporter. 



No. 1873. PHILADELPHIA, JANUARY 21, 1893. Vol. LXVIII— No. 3 



ORIGINAL ARTICLES. 



FIVE OASES OF VAGINAL HYSTERECTOMY FOR MALIGNANT DISEASE 
OF THE UTERUS.— ALL RECOVERED.* 



W. F. McNUTT, M. D., M. R. C. S., Ed., etc., San Francisco. 



Case I. Mrs. B., age 57, born in New 
York, had one child, 1851, no cancer his- 
tory, menstruated at 17, ceased at 41. 
At age 53 commenced having slight 
uterine hemorrhages; consulted several 
physicians in regard to it, had taken 
medicine and had astringent injections, 
etc., with the effect of partially controlling 
the bleeding. When she consulted me 
first at my office she had slight hemor- 
rhage, mixed with a thick, ropy albuminous 
looking discharge — found the uterus 
slightly enlarged, canal tortuous and ir- 
regular, and had difficulty in passing the 
sound ; neck granular and bleeding easily ; 
made applications with astringents, 
ordered lead and carbolic injections, ad- 
vised rest. There being no improvement 
and considering the case cancerous, I 
called Dr. Beverly Cole in consultation, 
when we dilated the uterus with Hager 
dilators. There was discharge of at least 
half an ounce of white-of-egg-like fluid 
mixed with blood, the whole neck of the 
uterus was nodular and presented an 
epithelial-like softened appearance. The 
woman was losing weight, strength and 
color ; there was no mistaking the diagno- 
sis, viz., epithelial cancer. 

Mrs. B., having consented to an opera- 
tion, I determined to make a vaginal 
hysterectomy, and on November 27th, 
1888, removed the uterus. The external 
parts were shaved and thoroughly cleaned 
by soap and carbolized water, the 
vagina was disinfected and the patient 
placed in the dorsal position. The uterus 

*Read before the California Medical Society. 



was brought down by a strong vulsella and 
a small vertical incision was made through 
the anterior vaginal wall. An aneurism 
needle with a ligature was passed through 
the opening, and brought out through the 
wall three-fourths of an inch to the right; 
this section was tied and divided with 
scissors; this process was continued until 
the neck was enucleated; the connective 
cellular tissue was mostly broken up by 
the finger; the uterus was then easily 
brought further down, not turned over, 
and the broad ligaments secured en masse 
by a carbolized silk ligature. I then put 
long compression forceps on the ligaments 
between the ligature and uterus, and 
divided the broad ligaments close to the 
uterus up to its upper margin, and over 
this undivided upper fold of the ligament 
I placed a ligature and cut the uterus free. 
I then tied these last two ligatures 
together stretching the broad ligaments 
across the cavity and making a roof, as it 
were, to the vagina; the vagina was then 
packed with iodoform gauze; the forceps 
were taken off in forty-eight hours. 
She was kept four weeks in bed; and seven- 
teen months after the operation she was 
as well as she ever was. At no time after 
the operation was there any marked rise 
in temperature. 

Of the pathology of this case Prof. D. 
W. Montgomery says: " Mrs. B. had an 
extensive neoplasm of the cervix uteri, 
both simple and malignant. The simple 
new growth was a papilloma. Below the 
papilloma was a epithelioma infiltrating 
very extensively the connective tissue." 



80 



Original Articles. 



Vol. lxviii 



Case II. Mrs. P., aged 44, married at 
20, two children, youngest 17 years old, 
had one miscarriage 13 years ago, no can- 
cer history. This case was under the care 
of Dr. W. H. Davies, who had attended 
her for several months for uterine hemor- 
rhage, using internal remedies, injections 
and several times having to tampon the 
vagina with cotton saturated with Monsel's 
solution. 

Dr. Davies told her his efforts were only 
affording her temporary relief and more 
radical measures would have to be tried. 
I was called in consultation and found the 
patient exsanguine to an alarming degree ; 
an epithelioma of the cervix was unmis- 
takable; the slightest touch caused profuse 
bleeding, necessitating the tampon after 
our examination. We advised removal of 
the uterus, and after a few days' delay she 
consented to the operation. July 25th, 
1889, the operation was made. I gave the 
patient ether, and, placing her in the 
lithotomy position, the epithelial fungoid 
bleeding mass was curetted off and the 
bleeding in a measure controlled by hot 
water before enucleation of the cervix was 
commenced. Drawing the uterus well 
down with a vulsella the enucleation was 
soon made, the adhesions separated, and 
the broad ligaments clamped with com- 
pression forceps (no ligatures used), uterus 
cut loose. The forceps were left on fifty 
hours. The only difficulty encountered 
in this operation was the exhausted and 
exsanguined condition of the patient before 
commencing the operation. During the 
latter part of the operation she was con- 
stantly plied with hypodermic injections of 
whiskey, which were necessary to keep up 
the heart's action. 

The patient was in excellent health and 
spirits nine months after the operation, 
with the exception that she has a small 
vesico- vaginal fistula, which did not 
give any evidence of its presence until 
after the fourth week. 

Case III. Hysterectomy (for cancer) 
and Ovariotomy — Double Operation. Mrs. 
F., age 67, a thin, wiry, but apparently 
well nourished old lady came to Dr. R. 
M. Elliott, of this city, from Washington 
Territory, on June 24th, 1889, suffering 
from an offensive discharge from the 
uterus. She had borne a large family of 
healthy children, and never had any severe 
illness up to the present time. 

While riding on a buckboard about five 



months ago, the horses in leaping a ditch 
tipped her backwards, and she fell, strik- 
ing on her sacrum. The injury caused 
her considerable pain at the time, but it 
gradually passed off leaving no noticeable 
trouble afterwards. A smooth, elastic, 
immovable, round tumor could be felt 
through the abdominal wall in the region 
of the ovary. There was a purulent vag- 
initis and an excoriation of the os uteri 
with a purulent bad smelling discharge 
from the os. There had been at no time 
either pain or hemorrhage. After cauter- 
ization by Dr. Elliott with nitrate of 
silver, (the solid stick), the excoriation 
healed in part, the discharge from the os 
in a great measure ceased, and she re- 
turned to the country much improved, 
but with a slight discharge from the 
vagina which still persisted, and for which 
an injection of sulphate of zinc and acetate 
of lead, each 20 grains, tincture of opium 
one drachm, and water to eight ounces, 
was prescribed. 

After two weeks she wrote stating the 
offensive discharge had returned just as 
before. On coming back to the city 
again for treatment a much more serious 
state of affairs was found than at first. 
The discharge was as abundant as before 
instituting treatment, and a fungoid, 
easily bleeding mass was seen projecting 
from the os uteri. 

Dr. Elliott called me in consultation 
and an operation was advised, the patient 
was sent to the Children's Hospital and 
the date of operation set for August 11th, 
1889. 

Because of the abdominal tumor, the 
exact nature of which could not be de- 
termined before the operation, it was de- 
cied to first open the abdomen, ex- 
amine its contents, and then act pro re 
nata. After a careful toilet, the ab- 
domen was opened in the median line, 
and an ovarian cyst about the size of a 
cocoanut was found united by extensive 
adhesions to all the^urrounding viscera, 
especially to the inlestines. The adhe- 
sions were carefully separated, principally 
by the finger nails, uifter much labor 
the tumor was set free rrom the intestines, 
it still being firmly adherent to the uterus. 
The cyst contents were. tjien evacuated. 
The uterus was found much enlarged; 
being about the size it should be at the 
second month of gestation; it was soft 
and boggy to the touch ; adherent to'ljj&e 



January 21, 1893. 



Original Articles. 



81 



surrounding tissues, especially posteriorly, 
an abscess being found between the uterus 
and the rectum. I then decided to enu- 
cleate the neck of the uterus per vaginam 
and remove the uterus through the ab- 
dominal opening. In enucleating the 
neck and going up between the rectum 
and the uterus the aforementioned ab- 
scess was opened and a large quantity of 
foul smelling pus was evacuated. The os 
uteri was also opened up and a large 
quantity of pus came away from the uter- 
ine cavity. The pus being got rid of per 
vaginam, and the neck being thoroughly 
enucleated, the operative procedures were 
subsequently carried on through the ab- 
dominal opening, removing the entire 
womb, the cyst in connection with it, and 
the left Fallopian tube. 

Despite the age of the patient, the 
length of the operation (lasting fully three 
hours) and the amount of disturbance 
caused by the breaking up of the very ex- 
tensive adhesions and the separation of 
such large masses of tissue, the patient's 
temperature never went above 101°, and 
the only bad symptom was some meteorism 
occurring on the third day and gradually 
subsiding again. Very little blood was 
lost during the operation ; a point of great 
importance in elderly persons in whom 
the blood-making functions are not active. 

Dr. D. W. Montgomery's report on the 
pathology of the parts removed, appeared 
in the reports of the San Francisco Medi- 
cal Society where the specimens were 
shown. He says that it was an epithe- 
lioma of the cervix uteri, the infiltrations 
involving pretty much the whole cervix. 

Case IV. Mrs. P., aged 32, married, 
had children, was under Dr. S. S. Stam- 
baugh's care for several months for fever, 
pain and uterine hemorrhage. I examined 
her in consultation with Dr. Stambaugh 
August 27, 1889; the uterus was much 
enlarged and immovable, cervix nodulated 
and vascular with granulating bleeding 
surface; broad ligaments thickened. 
There was a bad smelling vaginal dis- 
charge. There was no doubt about the 
cancerous nature of the disease. Mrs. P., 
came from a verv malarious locality, and 
had high fever every day, notwithstanding 
Dr. Stambaugh had treated her for 
malaria. 

We informed Mrs. P. of the nature of 
her disease, and that nothing but an oper- 
ation offered her any chance from a dis- 



ease which must soon prove fatal. The 
enlargement and fixed condition of the 
uterus with the involvement of the broad 
ligaments made the prospect for an opera- 
tion bad. She, however, wanted to avail 
herself of the chance an operation would 
afford, and on September 12, 1889, I 
operated. After careful preparations as 
to washing, shaving and vaginal antisep- 
tics, the uterus was seized with a strong 
vulsella, but on account of the fixed con- 
dition could be pulled down but little, the 
neck was soon enucleated with instruments 
which I had made for the purpose. 

The extensive adhesions were broken up 
with great difficulty, and the ligaments 
were so involved that it was necessary to 
remove them. 

The hemorrhage was controlled by com- 
pression forceps, which remained on about 
fifty-two hours; no ligatures used; the 
vagina filled, as in all the other cases 
with iodoform gauze, and the woman put 
to bed. She at no time had so much fever 
after the operation as she had before, and 
she made a good recovery. 

Case V. Mrs. W., aged 38, born in 
France, first menstruated at the age of fif- 
teen, never was regular; married at twen- 
ty-three, one miscarriage five years after 
caused by lifting a heavy weight, followed 
by metritis and peritonitis, was confined 
to bed two months, never fully recovered; 
no cancer history. 

Began to complain of uterine pain and 
hemorrhage about three months ago, 
for which she had consulted physicians at 
various times, who had given her medicine 
and injections without relief. She con- 
sulted Dr. Frances E. Marx, who, consid- 
ering the case cancerous, called me in con- 
sultation. On examination I found great 
tenderness ; the whole uterus enlarged and 
fixed; cervix indurated and nodular, with 
very vascular granulations which bled 
freely from the slighest touch; there was 
a constant watery, bloody colored dis- 
charge, having a characteristic odor; the 
cancerous cachexia was well marked and 
the diagnosis of cancer was unmistakable. 

Being informed of the. nature of her 
case and the only remedy, removal of the 
uterus, she at once consented to an opera- 
tion. She was sent to the Children's Hos- 
pital. December 3, 1889, I removed the 
uterus. On account of the large size and 
fixed condition of the organ, accompanied 
by the fact that the woman had never 



82 



Original Articles. 



Vol. lxviii 



borne children, the operation was a 
most difficult one. After enucleating the 
cervix and separating the adhesions to the 
bladder it was still impossible to pull the 
uterus down — the attempt to turn it over 
backward was equally unsuccessful. After 
a time, however, I succeeded in turning it 
over forward, having fixed one blade of 
the vulsella into the fundus and made 
steady traction. The broad ligaments 
were then clamped with compression for- 
ceps (no ligatures used), and the operation 
finished by cutting the broad ligaments. 
The vagina was packed with iodoform 
gauze and the forceps removed after forty- 
eight hours. This large fibrous tumor 
which you see in the fundus of the uterus 
is what prevented the uterus from descend- 
ing and made ix so impossible to turn it 
over backwards. 

The operation altogether was very diffi- 
cult, and the hemorrhage from this 
softened, vascular, broken down, cervical 
portion was excessive and uncontrollable 
during the operation. The woman, 
though exsanguine by the time the opera- 
tion was finished, made a good recovery, 
and is at present enjoying very fair health. 

The first operation was the only one in 
which I used the aneurismal needle and 
ligature in enucleating the cervix. In the 
other cases the enucleation was done with 
instruments which I made for the purpose. 

My object in reporting these cases is to 
call attention to the fact that we have in 
hysterectomy a remedy even for cancer of 
the uterus; to assist in establishing 
hysterectomy as a legitimate and recog- 
nized surgical operation, and to hasten the 
time when the surgeon will as promptly 
and confidently resort to removal of the 
uterus for cancer as he does to the re- 
moval of the breast. 

Of these five cases all were married 
women, four had borne children, while 
the fifth case had had one miscarriage. 

About the frequency of cancer of the 
body of the uteru3, as compared with that 
of the cervix, there is great diversity of 
opinion, as is also the case in regard to 
the merits of the operative procedure for 
cancer of the cervix — whether to remove 
the cervix only or to make hysterectomy. 

A recent able writer on cancer of the 
uterus, Dr. John Williams, Professor of 
Obstetrics in Queen's College, London, 
strongly advocates amputation of the 
cervix when the cancer apparently in- 



volves only the cervix, saying : " That it 
is possible to extirpate cancer from the 
uterus by supra-vaginal amputation, and 
that, in so far as the prevention of recur- 
rence in the uterus is concerned, total 
extirpation of the organ presents no 
advantages over partial amputation/' 

It is not so surprising that Dr. Wil- 
liams takes this ground, as he believes he 
has fully demonstrated that the tendency 
of cancer of the cervix is to spread later- 
ally rather than to follow up the uterine 
cavity and involve the body of the womb. 
A careful examination by Professor Mont- 
gomery of the uteri of my cases does not 
go to confirm Dr. Williams' opinion, that 
in cancer of the cervix the tendency is 
only to extend laterally. Dr. Mont- 
gomery found the cancer cell extending 
up the mucous lining of the uterine canal. 

While Dr. Williams advocates and prac- 
tices the supra-vaginal amputation, he 
certainly has failed to make it clear how 
we are to diagnose with any certainty in 
which cases there is no cancerous involve- 
ment extending above the cervix. 

There may be cases when this supra- 
vaginal amputation would be all that is 
necessary; in many cases, however, the 
cancerous tissue would not all be removed, 
and there is no means of differentiating 
the cases. 

In connection with these cases, I will 
crave the indulgence for a word about 
laparotomy. Now, that laparotomy has 
become so common, no one thinks of 
making an elaborate and detailed account 
of this operation. In the past year I 
have, however, made three or four that 
are not devoid of interest to those who are 
interested in abdominal surgery. 

Two of the cases appeared to be intra- 
ligamentous cysts. One very large, with no 
pedicle, was imbedded between the layers of 
the broad ligament deep in the pelvis. En- 
ucleation was first attempted, but the cap- 
sule was so vascular that the attempt to 
shell it out had to be abandoned. I 
finally tied its whole broad base in eight 
sections. Including too much tissue in the 
last section next to the uterus, the liga- 
ture cut the tissues and the bleeding was 
profuse. After cutting away the sac close 
to the ligatures, I resorted to powdered 
MonseFs to stop the hemorrhage, which it 
did, using about three teaspoonfuls. A 
drainage tube was used, and the wound 
closed in the usual manner. There was 



January 21, 1893. 



Clinical Lectures. 



83 



considerable inflammation, with a temper- 
ature of 104° for three or four days, when 
the fever subsided and the patient made a 
good recovery. She was out in five weeks. 
In the second intraligamentous case the 
cyst was small and there was no difficulty 
in enucleating it. The hemorrhage, how- 
ever, was very profuse, and was again 
checked by putting Monsel's freely into 
the bed of the cyst. A drainage tube was 
used. Some fever followed, and the 
woman made a good recovery. These 
two cases made up my experience with 
Monsel's in the abdominal caviby. Just 
how to manage these intraligamentous 
cysts seems to be a matter for each indi- 



vidual operator to determine after he has 
opened the abdomen and carefully exam- 
ined the case at hand. 

The third interesting case was that of a 
solid ovarian tumor weighing between 
seven and eight pounds. The woman, 
though very weak, made a good recovery. 
Professor Montgomery, after a careful 
examination, determined it to be fibroid. 
While solid ovarian tumors are not com- 
mon, the fibroid variety is probably the 
least common of all. The most trouble- 
some part of the operation for these solid 
tumors often is the management of the 
intestines, owing to the great length of 
the opening required to lift out the tumor. 



CLINICAL LECTURES. 



TALIPES FRACTURE OF ACKOMIAL END OF CLAVICLE, DOUBLE 
FRACTURE OF SHAFT OF FEMUR, HARE-LIP.* 

Prof. ROSWELL PARK. 



This patient is a boy four or five years 
old who presents a well-marked case of 
talipes equino -varus. His parents have 
been too poor to provide proper mechanical 
support for the foot and the boy has worn 
a very cheap, inefficient shoe which has 
been of no use in correcting the deformity. 
They consulted me with reference to an 
improved form of shoe but I told them 
that I should not recommend a shoe until 
after an operation. 

The question arises, is this a case in 
which the deformity is due to essential mus- 
cular weakness, or has the apparent atrophy 
of the muscles come about from lack of use 
of the foot ? The peronei tendons on the 
outside of the foot and leg act like a bridle 
rein opposed to the tibiales tendons on the 
inner side. Naturally, if the peronei are 
paralyzed, the foot will be turned in and 
I think the present condition is largely due 
to such trouble. Even if the weakness of 
the pe*ronei were not the original cause, the 
deformity is at least perpetuated by their 
present inability to overcome the pull of 
the tibiales. 

After cleansing the foot and leg and 
applying an Esmarch bandage, I will cut 
the tendo Achilles by the ordinary subcu- 
taneous method. You will ask why the 

* Buffalo General Hospital Surgical Clinic, reported 
by A. L. Benedict, A. M., M. D. 



Esmarch bandage was used. Certainly 
not for the almost bloodless section of the 
tendo Achillis, but because I intend to 
divide the tendons on the inner border of 
the foot by an open incision according to 
the operation of Dr. A. M. Phelps, of New 
York. After doing this, you see that the 
slightest touch restores the foot to its nor- 
mal position, the wound is closed by dust- 
ing iodoform over it and applying layers 
of iodoform gauze, bichloride gauze and 
cotton, and the whole is kept in place by a 
roller bandage. When the tourniquet is 
taken off, the blood will rusn back into the 
foot and an aseptic blood-clot will be thrown 
out to heal the wound, which I have made. 

This case being one due almost entirely 
to lack of muscular control of the foot, 
the bony deformity is not great and an 
operation on the tarsus is unnecessary. 
The foot is restored manually to its proper 
position and is held in a position of over- 
correction while I apply a plaster-of- Paris 
dressing. We have every reason to expect 
primary union under this dressing, by the 
organization of the blood-clot. The 
parents of the child must have directions 
about later using massage of the leg mus- 
cles to the best of their ability. Without 
some such means to stimulate the peronei 
and the sural muscles, the foot would 
relapse almost to its former state and con- 



84 



Clinical Lectures. 



Vol. lxviii 



siderable care must be taken to keep the 
foot in its restored position by making the 
external and posterior muscles do their 
proper work. 



This patient has sustained a fracture 
near the shoulder joint, the result of a fall 
on the shoulder. The doctor who first at- 
tended him diagnosed fracture of the 
acromion and applied a dressing which 
was not disturbed till I saw the case two 
days afterward. It struck me at the time 
that the dressing could not keep acromion 
in place as there was no provision for 
pushing the arm upward against this 
prominent process. On removing the 
dressings to see how much the acromion 
had dropped from its proper position, I 
found that it had not dropped at all, show- 
ing that it could not have been fractured. 
On manipulation, I got obscure crepitus 
which I succeeded in localizing at a point 
within half an inch or so from the junc- 
tion of the clavicle and the acromion so 
that we must modify the diagnosis and say 
that the case is one of fracture of the 
acromial end of the clavicle. You will 
ask what is the necessity of making such 
an accurate diagnosis. Because a corres- 
ponding accuracy of treatment is neces- 
sary. You must know what part is 
injured in order to know in what position 
to place the shoulder. If the clavicle is 
fractured, you must push the shoulder up- 
ward, outward and backward. If the 
acromion is fractured you must rather 
raise the arm in order to push up the 
broken piece. 

On inspecting the shoulder, you notice 
very little deformity. Apparently, the 
fracture is so near the joint that the outer 
end of the clavicle is held by the coraco- 
clavicular ligament and thus there cannot 
be much displacement. All that is neces- 
sary, then, is to hold the parts quiet by a 
simple retentive dressing. We have met 
this indication by part of the Sayre adhe- 
sive dressing passed around the arm and 
body, and, over this, a roller bandage has 
been applied and the hand is kept in a 
sling. I show you this case, not to call 
attention to any error on the part of 
another, for the original dressings were 
sufficient to keep the parts in place, but 
to emphasize the importance of making an 
exact diagnosis and to show you a com- 
paratively rare and fortunate location of a 
fracture. 



I also wish to call your attention to an 
interesting phenomenon and one which 
has here, something of a diagnostic value. 
Over the anterior and upper part of the 
chest you see an ecchymosis, not fresh as 
it would be from a recent superficial con- 
tusion, but showing the faded colors of an 
old extravasation of blood in which chem- 
ical changes have occurred. This is a 
common appearance after fracture of any 
bone, the blood working its way to the 
surface after several hours or after two or 
three days, according to the distance of the 
bone from the skin. Now, if the fracture 
had been one, of the acromion process, the 
ecchymosis would be seen over the peak 
of the shoulder and posteriorly on account 
of gravitation while the patient is lying on 
the back. The blood could scarcely pene- 
trate the deltoid muscle, so that the dis- 
coloration of the anterior part of the chest 
and the absence of such discoloration from 
the back and top of the shoulder are con- 
tradictory to the diagnosis of fracture of 
the acromion. Ecchymosis is practically 
of little value in the immediate diagnosis 
of fractures since it can not be seen till 
after the injury should have been located 
and the dressing applied. 



This patient is a victim of the boom at 
Niagara Falls, having been injured while 
at work in the tunnel by a large stone fall- 
ing on his thigh. The femur was broken 
in two places, just above the knee and ten 
or twelve centimeters higher. It is now 
six weeks after the accident and the case 
is brought before you as an illustration of 
the results of treatment. The patient is a 
young man of twenty-four, previously 
healthy ana we should expect that the 
necessity for confinement and rest in bed 
has passed away. I wish, however, to 
manipulate the limb to determine the de- 
gree of consolidation and to make sure 
that it is sufficient to warrant leaving off 
the dressing. As I grasp the bone through 
the soft tissues, it seems fully twice as 
thick as on the opposite side, this increase 
in size being due to the callus which was 
thrown out after the double injury 
and which has been more or less organized 
into bone. In course of time, most if not 
all of this enlargement will probably be 
absorbed. As I rotate the leg at the knee, 
the trochanter moves in correspondence as 
it should if the femur is again one piece. 
Grasping the femur with both hands, I am 



January 21, 1893. 



Clinical Lectures. 



85 



unable to make any motion in the middle, 
either by rotating it or by trying to bend 
the bone. 

I also wish to measure the leg to note 
the shortening, a moderate degree of which 
is to be expected after any fracture of the 
femur and especially after a double frac- 
ture. We must be careful to get the' legs 
perfectly parallel, having the pubes, 
umbilicus and internal malleoli in the 
same line. Measuring from the anterior 
superior spine of the ilium to the internal 
malleolus of the sound side first, I find 
the distance to be 33^ inches. I make it 
a rule never to look at the tape-line until 
after I have determined by the sense of 
touch the exact points between which to 
stretch the line. In this way I avoid any 
possible self-deception. I find the meas- 
urement of the injured side to be thirty- 
three inches. By the dictum of the 
American Medical Association, a shorten- 
ing of three-quarters of an inch is not a 
bad result and is quite consistent with the 
most skillful treatment. With a double 
fracture, it would not be at all surprising 
if an inch or an inch and a quarter of 
shortening had occurred. We must con- 
gratulate ourselves on having secured a 
minimum of it here. This has been ob- 
tained only by traction with a relatively 
very heavy weight, at first, of twenty 
pounds. Although consolidation has 
taken place, it would not be wise to allow 
the patient to get up and exert pressure on 
the bone, since some farther shortening is 
still possible, but he can be relieved of the 
irksomeness of the bandage. His leg will 
be rested on a pillow and passive motion 
will be used so as to allow the knee to re- 
cover its mobility. 



This case is a simple form of hare-lip 
occurring in a child aged sixteen months. 
The explanation of the trouble is easy if 
we understand a little about embryology. 
The two halves of the face are developed 
separately and grow toward each other. A 
cleft in the lip, like a cleft in the palate, 
indicates a failure of complete fusion of 
originally separate parts. In certain ani- 
mals, the hare especially, such a failure is, 
so to speak, intentional. In the human 
being it constitutes an abnormality and, 
on account of the disfigurement, it is one 
which the surgeon is often called upon to 
remedy. The . failure to fuse may be 



present in any degree from a slight notch 
in the lip to a fissue extending up the side 
of the nose and backward through the 
palate to the pharynx. Such extreme 
cases of combined fissure of the face and 
palate are almost beyond the full restora- 
tive power of surgery. Hare-lip, as well 
as cleft palate, is almost never found 
exactly in the median line. Many mothers 
try to explain its occurrence by recounting 
some fright which they had late in preg- 
nancy. The deformity, however, dates 
back to the fifth or sixth week of foetal 
life so that, without reference to the gen- 
eral possibility of maternal impressions 
affecting the child, such an explanation 
can not hold good in most cases of hare- 
lip and cleft palate. 

The operation for the relief of hare-lip is 
in theory a simple one. It consists in fresh- 
ening the edges of the cleft and sewing 
them together. In practice, however, this 
may be a very difficult plastic operation. 
I usually tell the parents that, although I 
can bring together the edges in any case of 
hare-lip, I can not ensure the union of the 
wound for the simple reason that the child 
in fretting and crying, may tear the 
stitches loose. We try to avoid this acci- 
dent by reinforcing our stitches. Some- 
times hare-lip pins are used to transfix the 
parts and a silk ligature is wound in figure- 
of-eight fashion over the ends of the pins. 
Sometimes sutures are passed through the 
cheeks and held by lead discs. Often the 
wound is dressed with iodoform and pro- 
tected with collodion, and some rely on the 
stiffening of the collodion to prevent the 
child from moving the lip in crying. But 
the discharge from the nostrils or the 
saliva or food may loosen the collodion so 
that this dressing often fails. 

Several operations have been devised to 
relieve different forms of hare-lip, all fol- 
lowing the same general principle but dif- 
fering in detail. For instance, we may cut 
parallel to one edge of the cleft, nearly to 
the margin of the lip and then turn inward 
so as to leave a tag of tissue at the lower 
part of the cleft. On the other side we 
do no remove as much tissue but we make 
a similar angle to aid in cooplating the 
parts. 

In this case the defect is so slight, not 
extending to the nostril, that it is necessary 
only to freshen the margin of the cleft. 

Our Continental friends have a way of 
operating on hare-lip without giving an 



86 



Commun ications. 



Vol. lxviii 



anaesthetic. I do not consider it any 
advantage to avoid the theoretical evil of 
giving an anaesthetic by allowing the child 
to suffer so much pain as the operaton 
necessitates. 

The alveolar border is not exactly regu- 
lar, but is nearly so and it requires no 
operative interference. The teeth are not 



quite regular and one is turned half way 
round and will require the attention of a 
good dentist at some future time. At 
present I forbear to do anything but rec- 
tify the labial fissure, lest with this rather 
feeble child I do too much, and perhaps 
totally fail. What remains to be done be- 
yond this may be better done a little later. 



COMMUNICATIONS. 

CEEEBEAL SYPHILIS.* 

Dr. J. E. HAYS. 



I have prepared this paper with the ob- 
ject of presenting in as condensed 
form as possible, the history of 
two cases of cerebral syphilis that have 
lately come under my care. 

An inteiesting feature of each case is the 
wide interval of apparent cure between the 
disappearance of the secondary manifesta- 
tions and the beginning of the cerebral 
disturbance. As both cases were ac- 
companied by paralysis which was hemi- 
plegic in character, they forcibly illustrate 
the danger and serious effects that may 
possibly result from the product of a syphi- 
litic dyscrasia. 

Case I. Mr. P., aged forty-six; an 
Englishman. I was called to see this case 
February 1st, 1892, and found him with 
complete paralysis of the left arm and leg ; 
his power of speech was slightly impaired, 
and there was also some difficulty in swal- 
lowing. The attack had been sudden and 
was not attended by any loss of conscious- 
ness. Prior to the loss of power on left 
side, there had been no complaint of pain 
in the head ; no vertigo ; no staggering or 
uncertain gait; in fact, no symptom that 
would indicate an approaching paralysis. 
His general health for many years pre- 
vious to the attack had been excellent; 
his habits had been regular ; he used noth- 
ing alcoholic nor tobacco in any form; his 
occupation was that of foreman in a large 
manufacturing establishment in this city. 

A careful inquiry into the previous 
history for something that would throw 
light on the cause of the hemiplegia revealed 
the following: At the age of twenty-six 
he contracted syphilis. The primary sore 

* Read before Medico- Chirurgical Society, Louis- 
ville, Ky., Dec. 9, 1892. 



was cauterized and internal treatment, the 
nature of which he did not know, con- 
tinuously administered for several months. 
Following the initial lesion had been some 
glandular enlargements, slight falling out 
of hair, but no eruptions on the face or 
body. From the history it seemed to me 
that there could be very little doubt in re- 
gard to the nature of the lesion that had 
occasioned his paralysis, and he was at 
once given iodide of potash in gradually 
increasing doses. For two months his im- 
provement was very satisfactory; in this 
time he had sufficiently recovered the use 
of his leg to enable him to walk about ; 
but his arm was still almost powerless. 
He looked, ate, and slept well. The 
amount of iodide of potassium had been 
increased to forty grains three times a day. 
A larger amount of the remedy was badly 
borne, and it was decided to continue this 
dose. On the sixth of April he developed 
a severe pleurisy on the left side ; this was 
attributable to an exposure immediately 
after taking a Turkish bath. Dr. Bailey 
saw the case with me a few times during 
this attack; an effusion of moderate 
amount took place in the pleural sac, but 
disappeared under treatment in a few days. 
On April 20th, pleurisy occurred on the 
right side ; this was also attended by effu- 
sion, not as great, however, in amount, as 
that had been on the left side. Shortly 
after the disappearance of this, he was 
seized with a violent bronchitis which so 
closely simulated tubercular phthisis that 
for a while it was calculated to deceive, 
esjoecially as the attack was attended by 
persistent cough, profuse yellowish expec- 
torations, rapid loss of color and strength, 
night sweats and a fever somewhat hectic 



January 12, 1893. 



Communications. 



87 



in character. His treatment at this time 
was mainly the syrup of hydriodic acid, 
a generous allowance of port wine, and 
plenty of liquid food. Later he was also 
given the compound syrup of the hypo- 
phosphites. His improvement for several 
weeks was very slow ; the chest symptoms 
did not entirely disappear until September. 
Since then, under the use of iodides and 
Faradism, he has made considerable pro- 
gress towards regaining the use and 
strength of the paralyzed limbs. A few 
weeks ago he resumed his work at the 
factory. 

Case II. Mr. J. , aged forty-two ; car- 
penter. This is a somewhat similar case 
to the one just reported. I saw him 
shortly after the attack of hemiplegia, and 
elicited the following facts : Eighteen 
years ago he had an indurated sore on the 
penis; secondary manifestations followed, 
but slight. He did not remember the 
duration of the treatment, but said that 
he continued to take medicine until the 
physician pronounced him cured. Since 
abandoning the treatment there had been 
no further outbreak on his skin ; he mar- 
ried and has a son living, aged fifteen, 
whose upper central incisors on examina- 
tion showed the characteristic malforma- 
tion of inherited syphilis, as described by 
Hutchinson. The patient's health, not- 
withstanding bad hygienic surroundings 
and habits, had remained in good general 
condition until last May. At this time 
symptoms of vertigo made their appear- 
ance, and soon became well marked and 
persistent. In walking he felt an almost 
continual tendency to pitch forward and 
to the left side ; his mind frequently be- 
came confused and his memory was poor. 
On account of the dizziness he was com- 
pelled to quit his work. The physician to 
whom he applied for relief, overlooking 
the true cause of the trouble, and think- 
ing that the vertigo was stomachal in ori- 
gin, advised him to quit the use of stimu- 
lants to which he was somewhat addicted, 
live on a spare diet, and keep his bowels 
freely moved by the daily use of a laxative 
water, the Carlsbad preferred. This failed 
to give relief. On the 2nd day of June 
left hemiplegia occurred ; complete loss of 
motion but no lessening of sensation of 
the arm and leg. There was no loss of 
consciousness, slight if any impairment of 
his intellectual powers; he could articulate 
distinctly, but talked slowly and with some 



effort. There was no diminution in the 
acuteness of his vision. 

The history given by the patient having 
established such a clear connection between 
syphilis and his present condition, he was 
at once given large doses of iodide of 
potassium. This was increased until he 
received as the maximum amount 180 
grains daily. In addition to this he has 
at intervals also received a small or 
"tonic " dose of the bichloride of mercury, 
and Huxham's tincture of cinchona. His 
progress toward recovery has been rapid 
and uninterrupted; he has gained about 
twenty pounds in weight; feels well and 
can easily walk several squares without a 
cane. He has, however, regained but lit- 
tle use of the arm. He will probably 
never be able to resume his accustomed 
work. 

The treatment of these cases presents 
no novelty. Clinical observation has long 
taught us that iodide of potassium is the 
sovereign remedy for bringing about an 
absorption of these products of syphilis. 
Its effect on gummata is well known and 
positive. While the mercurial prepara- 
tions properly administered may aid, they 
do not approach in effectiveness the iodine 
compounds. Mercury, however, in the 
early stages of the disease has the supre- 
macy. We very justly ascribe to it a direct 
and destroying effect on the virus of 
syphilis, whatever that virus may be. 
This being true, the opinion very generally 
prevails that it is only after a most careful, 
intelligent and prolonged treatment by 
mercury, that a physician can promise 
exemption from the later or so-called terti- 
ary manifestations. In regard to a disease 
so grave in its possible results as syphilis, 
this fact ought not to be forgotten. 



Black Eye, 

There is nothing to compare with a tinc- 
ture or a strong infusion of capsicum an- 
nuum, mixed with an equal bulk of muci- 
lage or gum arabic, and with the addition 
of a few drops of glycerine. This should 
be painted over all the bruised surface 
with a camel's hair pencil, and allowed to 
dry on, a second or third coating being 
applied as soon as the first is dry. If 
done as soon as the injury is inflicted, the 
treatment will invariably prevent the black- 
ening of the bruised tissue. The same 
remedy has no equal in rheumatic, sore, or 
stiff neck. — Med. Times. 



88 



Communications. 



Vol. lxviii 



SAECOMA OF THE BEE AST AT THE AGE OF SIXTEEN YEAES: 

OVARIAN CYST.* 



A. M. CARTLEDGE, M. D. 



I have two specimens to present, 
one of which I think is of special 
interest. A short time ago I saw 
in consultation a girl sixteen years of 
age, with the history that six months 
before there was observed in the right 
mammary gland a tumor the size of an 
ordinary marble, about midway between 
the nipple and the axilla. 

Her physician, on account of the girl's 
age, kept her under observation for a 
while, but in the last month he noticed 
very rapid growth of this tumor, and 
at the last examination, a week or ten days 
ago, he observed one enlarged gland in the 
axilla. He also observed at the last exami- 
nation that the superficial veins over this 
tumor were very much enlarged. The 
girl complained of lacinating pain. As I 
said she was only sixteen years of age, and 
apparently very robust in health. 

On examination a tumor of a distinctly 
movable character, the size of a goose egg, 
could be felt in the breast indicated; 
it seemed as if you could grasp it and it 
could be moved separate from the gland 
substance proper, and it was slightly lobu- 
lated. Below this tumor was a distinct 
second nodulation with a groove between 
the two. It seemed to correspond, as it 
took a more backward direction, to the 
lymphatic vessels going from the breast to 
the axillary space. At this examination I 
only felt one enlarged lymphatic gland in 
the axillary region. 

As to the question of diagnosis in this 
case, of course it would present some 
features of interest. Here we had a girl 
whose age was decidedly against malignant 
tumor of the mammary gland, with a clini- 
cal history of six months duration and of 
pain ; enlargement of the superficial blood 
vessels and enlargement of the lymphatics 
in the axillary. From the history" of the 
case I had no hesitancy in pronouncing it 
sarcoma. It presented every evidence of 
malignant growth and the age of the 
patient excluded carcinoma. There was 
no history of trauma. 

Believing that all neoplasms of the 
breast, without exception, should be sub- 

"*Re d before Medieo-Chirurgical Society, Louisville, 
Ky., Dec. 9, 1892. 



jected to complete extirpation and 
cleaning out of the axillary space, I 
advised this and the operation was done 
three days ago. The entire breast was re- 
moved, and you will observe that the 
tumor is distinctly encapsulated, entirely 
separate from the breast substance itself. 
The glands removed were simply the 
lymphatics. A thorough microscopical 
examination has not yet been made of the 
tumor. 

Certainly the growth, as it appears since 
its removal, more than ever bears out the 
opinion that was conceived of it before- 
hand, and it has every evidence of a sar- 
comatous growth. The tumor presents 
some appearance of a fibroma superficially, 
but just beneath it we have this clear 
metastasis, with enlarged lymphatics show- 
ing its malignant character. The exami- 
nation thus far has been a very rough one, 
the gentleman simply making a section 
without coloring it. He believed it would 
prove to be an interstitial mammitis of the 
breast, probably inflammatory. But the 
encapsulated condition indicates clearly to 
me that it is a sarcomatous growth, or a 
fibroma that has undergone sarcomatous 
degeneration, which we know is so common 
in this location. It does not present many 
features of an adenoma, but even this 
should be subjected to the same treatment. 

The age of the patient is one of the 
most peculiar features. One gentleman, 
who has written on this subject, claims 
that the earliest age in any case of sarcoma 
occuring in the female mammary glands 
is eighteen years. However, there has 
been one case reported in this city at the 
age of fourteen. I am certain that all 
such growths will be considered malignant 
by me from a clinical standpoint. 

Case 2. This specimen is of greater in- 
terest to the general practitioner than to 
surgeons. My attention was called to the 
case while visiting another patient in the 
same house. The lady said she had been a 
sufferer with dyspepsia for a long time; 
that she had to live principally on fluids, 
etc. I thought I recognized in her face 
the peculiar expression indicating ovarian 
disease. I made a careful examination 
and found a clear case of cyst of the ovary. 



January 21, 1893. Communications. 



89 



Operation was performed to-day; tumor 
removed weighing between thirty and fifty 
pounds; there were no adhesions; patient 
bore the operation well; when she was 
taken off the table pulse was 80 ; she had 
no shock and nothing to indicate further 
trouble. This case is interesting from the 



fact that the woman had never complained 
of anything except dyspepsia and there 
was nothing to indicate presence of the 
cyst, except the enlargement which might 
have been due to other causes. The patient 
never suffered any severe pain or incon- 
venience from the presence of the tumor. 



CLINICAL AND EXPERIMENTAL CONTRIBUTION TO THE TREATMENT 
WITH CREASOTE OF PULMONARY TUBERCULOSIS. * 



Dr. ALBU, in Berlin. 



In the Moabit Hospital in Berlin, crea- 
sote has been employed in constantly in- 
creasing doses since June, 1887, and es- 
pecially latterly since the publication of 
Dr. Sommerbrod, in Oct. 1891, has the 
remedy been employed in many cases of 
various stages of the disease. The remedy 
was administered in pill form of 0.05 
grammes each, and the average patient 
reached in the course of two weeks sixty 
pills per day. Many patients took 5,000 
such pills in the course of a few months, 
and some even 9,000 pills, equal to 450 
gramm (nearly a pint) of the creasote. 
No especial difficulty was found in the ad- 
ministration of these immense doses. 

While Sommerbrod in the beginning 
recommended creasote only as a very useful 
remedy in the symptomatic treatment of 
phthisis, of late he urged it as a successful 
remedy against tuberculosis, by which in 
fact severe forms with cavities could be 
permanently healed. In a pamphlet of 
recent date he recommends creasote even 
as specific for tuberculosis, his recommen- 
dations being based upon clinical exper- 
ience. 

In view of this, experimental researches 
were made at the Moabit Hospital, and 
these, as well as the experimental investi- 
gations of P. Guttmann, Coze and Simon, 
Sormani and Pellacani, Schuller and fin- 
ally of Cornet, proved negative in the 
great majority of cases. 

The author points out the importance 
of appreciating the effects really due to the 
remedy, in view of the natural variations 
in the clinical course of pulmonary 
phthisis, and finds that in a critical in- 
quiry as to its effect upon the chief symp- 
tom which reflects the real disease pro- 
cess, the fever, the remedy is without any 
effect whatever, as it is also upon the 

*Translated from the Deutsche Medicinische Woclien- 
schri/t for Dec. 15, 1892. 



etiological factor of the disease. No 
material, lasting change in the presence 
of tubercle bacilli in the expectoration has 
been observed in any case ; and under the 
continued administration of large doses of 
creasote the development of cavities, pneu- 
mothorax, amyloid degeneration, etc., has 
been observed; even in the early stages, 
the disease has frequently had a rapid 
course despite the treatment. On the 
other hand, the accomplished improve- 
ments were not greater than those secured 
under a purely hygienic-dietetic manage- 
ment—a conclusion which is based upon 
a great number of comparative investiga- 
tions. 

Under the favorable influence of the 
latter, improvement in the subjective and 
objective symptoms has been frequently 
observed in a short time; as for instance in 
a porter who under three different methods 
of treatment — tuberculin injections, hy- 
gienic-dietetic management, and large 
doses of creasote, each, time gained from 
eight to twelve pounds in weight in the 
coarse of eight weeks in the hospital. 

Creasote appeared to act favorably in 
many cases only through its influence upon 
the expectoration and digestion. 

In common with Th. Weyl, the author 
demonstrated that the introduction of 
large doses of creasote into the blood is 
without influence upon the tubercular pro- 
cess in the lungs ; the sputum from such 
cases having been found fully virulent for 
animals. Inoculation of such sputum 
into the anterior chamber of the rabbit's 
eye was followed by typical tuberculosis, 
and in all test animals tubercle bacilli 
were found in great numbers in the iris 
and cornea. 

Intraperitoneal injections upon guinea 
pigs of sputum from patients who had 
taken many thousands of creasote pills, 
were followed by general, miliary tuber- 



90 



Society Reports. 



Vol. lxviii 



culosis, the latter being confirmed by 
bacteriological examination. 

The results of the investigations which 
will hereafter be reported in detail in the 
Zeitschrift fur Hygiene und Infections- 
KranTcheiten show beyond doubt, as do 
also the clinical results witnessed, that 
creasote is without influence upon the 
tubercle bacilli, and upon the specific 
tubercular process in the lungs. 

Similar results with the same conclu- 
sions were reached in this country by Dr. 
Karl von Buck, of Asheville, N. 0., who 
made his investigations in his private in- 
stitution for phthisical patients, and who 
speaks of his present employment of crea- 
sote in a recent paper as follows: " Crea- 



sote is used only for its influence in 
overcoming fermentative processes in the 
alimentary canal, when less unpleasant 
means fail to succeed, and for its stimula- 
ting effect upon the mucous surfaces. 

I have become absolutely satisfied that 
creasote has no specific effect upon the 
tubercular process and have demonstrated 
that inoculations with tubercle bacilli of 
blood serum from a patient absolutely 
saturated with creasote by large and long 
continued dosage show luxuriant growths 
of the germs, not differing from cultures 
in serum where creasote had not been 
given, also that the germs from such 
patient's sputum produce virulent cul- 
tures." — 



SOCIETY REPORTS. 

THE MEDICAL-CHIRURGrlCAL SOCIETY OF LOUISVILLE. 

Stated Meeting of December 9t7i, 1892. 



The President, Dr. E. C. Simpson, 
in the chair. 

URTICARIA. 

Dr. D. T. Smith : This young man has 
been in excellent health since childhood, 
with the exception that he had spasms for 
a short time during infancy, such as any 
child might have. These spasms never 
occurred after he was two years old. He 
had no other form of illness until he was 
fifteen years of age, when he had an attack 
of malarial fever, which lasted two weeks, 
and after that an attack of typhoid fever. 

Before the attack of typhoid fever he 
felt at one time an itching over the right 
orbit, and reaching up his hand to ascer- 
tain what it was, he felt a tumor about 
the size of a wine grape projecting. That 
tumor disappeared, then it came again, 
this time slightly larger than before, and 
immediately over the left orbit ; dis- 
appearing and again appearing in his ear, 
then on his cheek, then on his lip, once 
inside of his mouth ; two or three times 
on the back of his head, and when I first 
saw him about four weeks ago, the tumor 
was disappearing under the right eye. 

These tumors are rather soft, except in 
the middle where there is a little more re- 
sistance to be felt. Four evenings 
ago he felt a twinge just over his right 
eye, and reaching up his hand felt the 



tumor coming there. I saw it the next 
morning. It had then spread some and 
was projecting probably twice as much as 
you see now. It comes and goes very 
quickly — he will simply feel a little itching, 
put his finger to the spot and the tumor is 
there. There is no sore upon his skin ; 
however, there is one little place which 
does not change, probably a mole, seem- 
ingly a little thickening of the skin form- 
ing a small lump. He compares these 
tumors as they pass away to the condition 
as observed in this spot that does not 
change. 

DISCUSSION. 

Dr. Wm. Cheatman : It looks to me 
more like urticaria than anything else. 

Dr. W. L. Rodman : How long do these 
so-called tumors remain out — that is for 
what length of time can they be detected 
from external appearance ? 

Dr. D. T. Smith : Sometimes two or 
three days ; at other times they will appear 
and disappear in a very short time. Prob- 
ably the average time is about two days in 
one place. 

Dr. A. M. Cartledge : It strikes me 
that it is a misnomer to call this condition 
a tumor. I do not think it can be 
properly classed as a tumor. When Dr. 
Smith first described it, I thought it was 
probably a blood extravasation. I have 
seen several cases of subcutaneous hem- 



January 21, 1893. 



Society Reports. .91 



orrhage of the scalp which had some re- 
semblance to this case. Since making an 
examination, however, I think it is neu- 
rotic. The case more properly comes 
under nervous irritation, or a vaso motor 
paresis. 

Dr. A. M. Vance : I believe the 
trouble is urticaria ; I do not see what 
else it can be ; it looks and feels to me 
like urticaria. 

Dr. W. L, Kodman : I am fully satisfied 
that these swellings are not tumors. The 
whole history of the case clearly excludes 
all possibility of tumors or neoplasms. No 
tumor could grow in so short a time, and 
disappear so rapidly. I take the view 
that Dr. Vance does, and am satisfied, that 
it is a disease of the skin. 

Dr. D. T. Smith : I agree in the main 
with what Dr. Cartledge has said : He 
stated, I believe, that it is vaso motor pare- 
sis. I think this enlargement is due to 
paralysis of the nerves controlling the ca- 
pillaries and arterioles, allowing an accumu- 
lation of fluid in them, mostly blood. At 
first there is a little discoloration, and finally 
a very slight ecchymosis, the skin seeming 
to be involved to that extent. And yet this 
tumor has appeared once inside of the 
mouth. While the origin of the trouble is 
in the nerve control, yet I think it is re- 
motely related to urticaria. Oases of this 
kind must be very rare, as there is so little 
record of them. I shall look further and 
it may be that I shall find some reflex 
cause. There is no organic change in the 
brain as shown by the migratory character 
of the tumor and the trouble must be func- 
tional. The reflex may be in the stomach, 
but I have not been able to find it. I have 
not examined the nose ; however, there 
has been no complaint. The patient has 
been in perfect health, and I have been 
unable to find the least trace of history of 
any other trouble. I must still denomi- 
nate this a tumor, though, of course, I 
am aware it has nothing of the nature of 
a neoplasm. 

Dr. A. M. Cartledge reported a case 
of Mammary Sarcoma in a Girl of 
Sixteen Years ; Also a Case oe 
Ovarian Cyst. (Page 88.) 

DISCUSSION. 

Dr. W. L. Eodman: I agree with Dr. 
Cartledge in what he says concerning his 
first specimen; I am satisfied from the 
appearance of the growth and its clinical 



history there can be doubt as to its malig- 
nancy, and, being satisfied of this — 
whether it be carcinoma or sarcoma — the 
proper procedure was complete removal. 

According to S. W. Gross, the youngest 
case in which carcinoma of the mammary 
gland has occurred was twenty-one years. 
This was in the practice of Henry. His 
statistics show the youngest case of sar- 
coma of the mammae to have been fourteen 
years of age. One case has been reported 
to this Society where the patient was not 
even thirteen years old. I think there is 
very little doubt about the specimen pre- 
sented being a sarcoma, and the Doctor 
did the proper operation, removing the 
entire breast and cleaning out the axilla. 

In reference to glandular enlargements 
in these cases, I disagree with Dr. Cart- 
ledge. While the rule is not to have in- 
volvement of the axillary glands in sarco- 
mata of the breast, still there are other ex- 
ceptions besides the case under discussion. 
Gross reports several I know. We also 
know that according to Butlin, sarcomas 
of glandular organs, especially the tonsil, 
testicle and lymphatic glands, are more 
likely to be followed by enlargement of 
the lymphatic glands than even carcinoma 
in like situations. The old idea that 
sarcoma never causes glandular involve- 
ment must pass away. 

Dr. A. M. Vance: I agree with what 
has been said, and believe the condition 
of this tumor was such as to justify com- 
plete removal of the breast. 

I would like to put on record a case I 
saw this summer : A very intelligent lady 
forty-five years of age, consulted me in re- 
gard to a tumor of the breast, which was 
hard and painful at the time. I gave the 
usual stereotyped opinion that all tumors 
of the breast in a woman over thirty, 
ought to be removed, and advised immedi- 
ate removal. Operation was refused, and 
I did not see the patient for about a 
a month, when she again called upon me 
I made a second examination of the tumor 
and it was then about half the size it was 
at the first examination. I will say, how- 
ever, on the occasion of her first visit to 
me I advised the removal of corsets, which 
she had probably been wearing tightly 
laced, as she was quite a fleshy woman. 
At the second examination, notwithstand- 
ing the fact that the tumor had consider- 
ably decreased in size, I still advised its 
removal. At that time she told me that 



92 



♦ 



Society Reports. 



Vol. lxviii 



she attributed the disappearance of the 
tumor to the influence of prayer. In an- 
other month she returned and the tumor 
had entirely disappeared, and she wanted 
me to make a statement that I had ex- 
amined her on a certain date, finding can- 
cer of the breast; had examined her on 
another date and found the cancer about 
half of the size, and again on such and 
such a date when the cancer had totally 
disappeared. 

This is the first case in my experience 
where tumor of the breast has disap- 
peared. Dr. Hays will remember another 
case where the tumor was not in the 
breast but in the pectoral muscle just an- 
terior of the axillary space. In this case 
both Dr. Hays and myself thought it was 
cancer and advised early removal. This 
patient consulted some " Faith Doctor/' 
and the tumor entirely disappeared. 

Dr. W. 0. Roberts : I am sorry that I 
did not hear Dr. Cartledge's report of the 
tumor of the breast. Of course the 
younger the subject the more apt it is to 
be sarcoma. We find many cases of sar- 
coma of the breast that have gone on for 
some time, and others which have grown 
very rapidly with no glandular enlarge- 
ment in the axilla. I remember one case 
not very long ago where there was very 
rapid growth, so rapid in fact, that the 
physician in attendance took it to be an 
abscess of the breast and lanced it, evacu- 
ating nothing but blood. I afterward re- 
moved the growth and found no enlarge- 
ment of the glands in the axilla. The 
character of the growth of course influ- 
ences to a great extent the enlargement of 
the glands. We have glandular enlarge- 
ment nearly always in melanotic sarcoma, 
which goes through the system not only 
through the blood, but through the lymph- 
atics; we have this sometimes in other 
forms of sarcoma, but chiefly in the melan- 
otic. 

In this connection I would like to refer 
to the case of melanotic tumor removed 
from the groin of a very fleshy woman, 
which I reported some time ago, Dr. Rod- 
man assisting in the operation. Within 
the last month there has been a recur- 
rence of the disease, there are several tu- 
mors on the body but not at the point 
from which the original growth was re- 
moved. 

Referring to what Dr. Cartledge has 
said about the ovarian cyst, I recently 



reported a case where I operated upon an 
old umbilical hernia, the patient being an 
exceedingly fleshy woman and had not 
suspected ovarian tumor, nor had I, my 
attention having been directed to the irre - 
ducible umbilical hernia. During the oper- 
ation for hernia the patient had a very se- 
vere vomiting spell, a great deal of the intes- 
tines protruding through the opening, 
and I detected a large ovarian tumor, 
which was promptly removed. My exper- 
ience is that ovarian tumors are very fre- 
quently run across, just as in the case 
reported by Dr. Cartledge, by accident. 

De. D. T. Smith: Dr. Douglass 
Morton used to insist upon a point in 
reference to removal of the glands in the 
axilla that seems to me entitled to much 
weight, that is the danger of recurrence 
in the axilla was so limited that it did not 
justify removal of the glands. I notice 
most leading surgeons, however, are still 
urging the course recommended by Dr. 
Cartledge — the removal of all the glands 
of the axilla at the time the breast is 
removed, making a complete operation. 
If it is true that in only three per cent, of 
the cases cancer returns in the axilla, 
then it does seem to me that the condi- 
tion hardly warrants such a complete 
operation. I saw some time ago a report 
by Bigelow, I think, of Boston, where he 
had collected all the cases of cancer of the 
breast he could find, and only three per 
cent, of them had recurred in the axilla, 
all the rest recurring in the scar. In 
view of this, I think the complete removal 
of the axillary glands in all cases to pre- 
vent recurrence in so small a percentage, 
is hardly justifiable. I would like to 
know if any of the members present have 
any statistics on the subject. 

Dr. W. L. Rodman: The best results 
which have been obtained in the operative 
treatment of malignant disease of the 
breast is by a free incision, removing all 
the glands, and also invading the axilla 
and removing all enlarged glands and 
other suspicious tissue. This done we get 
results second only to operations for the 
removal of carcinoma of the lip. Dennis' 
statistics made from a large number of 
cases of malignant disease of the breast 
treated by free incision are so good as to 
approximate in results operations for 
epithelioma of the lip, the best in the 
field of operative surgery for malignant 
disease. 



January 21, 1893. Society Reports. 



93 



Dr. A. M. Vance: In operations of 
this character at the Johns-Hopkins Hos- 
pital, I observed, while there recently, 
that they not only cleaned out all the lym- 
phatic glands of the axilla, but also re- 
moved all the pectoral muscle on the side 
affected. Dr. Halstead claims that this is 
the only way you can hope to entirely re- 
move the cancer. I believe that the wider 
you go the better it will be. 

Dr. A. M. Oartledge: I have very 
little to say in closing. One point in re- 
gard to lymphatic enlargements in sar- 
coma, carcinoma and other tumors of the 
breast — there is something in what Dr. 
Smith says in that it gives a suggestion as 
to the causation of lymphatic enlargements 
in growths of the mammary glands. I am 
-a firm believer that originally and primar- 
ily many tumors, and very much of the lym- 
phatic enlargement of the axilla, are in- 
flammatory in character from the absorp- 
tion of pyogenic micro-organisms rather 
than from metastasis. 

In regard to cleaning out the axilla, I 
think the best way to prove to Dr. Smith 
that this should be done, is that twenty- 
five years ago the percentage of recurrence 
in removal of cancers of the breast was so 
great, that many of the best surgeons ad- 
vised against the operation. Later they 
removed the cancer and the lymphatic 
glands, and their percentage of recoveries 
was still greater. Now they go still fur- 
ther than this and remove the pectoral 
muscles and the results are more satisfac- 
tory. I believe that the more structures 
you remove, within reason, the better the 
result will be. 

Dr. D. T. Smith: It still seems to me 
"hardly necessary or justifiable to remove 
the pectoral muscles and lymphatic glands 
in these cases, considering the small per- 
centage of recurrence in the axillary re- 
gion. In the older operations spoken of 
by Dr. Oartledge, I am forced to believe 
~that if there had been more complete re- 
moval of the cancer itself, the percentage 
of recurrence would have been much less. 

Dr. A. M. Oartledge : If you remove 
a cancer of the breast ever so thoroughly 
and then slit up the enlarged lymphatic 
glands and submit them to a microscopical 
• examination, usually cancerous elements 
will be found there. 

Dr. J. B. Hats read a paper on " Ce- 
rebral Syphilis." (Page 86). 



DISCUSSION. 

Dr. A. M. Vance : I only want to speak 
of one thing that has been brought up by 
the paper. My experience proves to me 
the importance of mercurial treatment in 
these cases just as much as in the primary 
stage. I believe that a patient suffering 
from syphilitic trouble must take about so 
much mercury before he can be entirely 
relieved. Though iodide of potassium 
might bring about the same results, it is 
a question whether such results would be 
permanent. While we all know the good 
effects of iodide of potassium in these 
cases, it is my opinion that if mercury 
were given in proper doses from the begin- 
ning of the first symptoms, the results 
would be better and more permanent. 

Dr. A. M. Oartledge : I would like to 
ask Dr. Hays how much mercury he would 
advise in these cases, and the dose given 
in these cases, and the cases referred to. 

Dr. J. B. Hats: I believe the dose 
has to be regulated as to quantity by each 
individual case. I gave in the two cases 
reported one-fiftieth of a grain. 

Dr. 0. W. Kelly: I have never given 
mercury in any stage of syphilis ; I much 
prefer iodide of potassium, and believe 
this will produce much more satisfactory 
and more certain results. 

Dr. W. 0. Roberts : I think in these 
cases we should push iodide of potassium 
to the extent that the patient is able to 
bear it. I had a case of brain syphilis 
some time ago with Dr. Bodine in which 
we steadily increased the quantity of 
iodide until the patient took one and one- 
half ounces per day — one-half ounce at a 
dose three times a day. This quantity 
produced no trouble in the alimentary 
tract, but he had most excessive duresis, 
passing enormus quantities of water during 
the time he was taking these large doses of 
iodide ; it was given very largely diluted. 
This treatment cleared up the brain en- 
tirely ; the man is now seemingly in per- 
fect health; has since married and has two 
children. 

Dr. Wm. Cheatham: It is my practice 
to treat syphilis, in either the first, second 
or third stage, with a combination of 
iodide of potassium and mercury. I be- 
lieve that in brain syphilis mercury given 
by inunction will produce better results 
than when given by the stomach. 

Dr. A. M. Oartledge : I am satisfied in 
my own mind that while we all have about 



94 



Society Reports. 



Vol. lxviii 



the same things to use in the treatment of 
syphilis in the various stages, first, second 
or third, the remedies, mercury and iodide 
of potassium being the chief, the manner 
in which we use them has a great deal to 
do with whether we have success or failure. 
In those cases where we have deposits 
pressing upon delicate structures, where it 
is desirable to remove them very quickly, 
such as the cases referred to by the essayist, 
I believe that we get the most rapid 
results by confining ourselves to the one 
remedy, iodide of potassium. I think 
mercury is a valuable agent in syphilis, 
but there is a difference in the action of 
these two agents. One point that I desire 
to call especial attention to is this, that at 
the same time we are administering iodide 
of potassium, we should also establish 
systemic drainage; this can be accom- 
plished by two-grain doses of calomel. I 
also think quinine may be given in these 
cases with a great deal of benefit. 

Dr. S. 0. Dabney: I see a good many 
cases of syphilis in the tertiary stage, and 
occasionally meet with the secondary form 
in diseases of the eye, nose and throat, less 
often in the ear. In these cases I have 
used mixed treatment with good results. 
I will mention as a fact of some interest 
a case of syphilis I saw recently in which 
there was paralysis of one of the muscles 
of the eye within four months after the 
first inoculation. The occular paralysis 
developed earlier and more rapidly in this 
case than it usually does. Disorders of 
the occular muscles and of the pupils are 
common symptoms in brain syphilis, but 
as they did not occur in the cases reported 
by Dr. Hays, it would probably not be 
in place to discuss them here. 

Dr. D. T. Smith: In my experience I 
have have only seen one case of brain 
syphilis ; this patient was about thirty-six 
years of age, a carpenter by trade. Diag- 
nosis was made of cerebral syphilis, which 
was first noticed by his staggering walk. 
I had him under observation for nearly 
three years and think there could have 
been no doubt as to the diagnosis. He 
was given large doses of iodide of potas- 
sium, probably up to twenty grains three 
times a day ; I also pushed corrosive subli- 
mate up to one-sixteenth of a grain. He 
went back to his work under my treatment. 
He fell from a house at one time being 
pretty badly crippled, which may have had 
something to do with aggravating the 



trouble. After that he grew better, then 
worse and finally became insane and was 
sent to the asylum, where he died. I be- 
lieve in these cases of cerebral trouble we 
may very often be mistaken in the diag- 
nosis, as to whether there is a syphilitic 
lesion or not. 

Dr. 0. Skioter: In treating syphilitic 
cases, I give mercury by inunction pre- 
ference in the second stage; iodide of 
potassium in the third and nothing in the 
first. My reason for giving nothing in 
the first stage is to be positive about the 
diagnosis. I use mercury in the second 
stage by inunction which I think is the 
best way to give it, keeping the bowels 
open and saving the stomach. In the third 
stage I give large doses of iodide of potas- 
sium, gradually increasing. I will men- 
tion a case of cerebral syphilis in which a 
man failed to carry out directions, which is 
just in line with Dr. Hays' paper. I 
treated this man's wife in an abortion; 
some time afterward I attended her in a 
second abortion; then she came to me in 
her third pregnancy and wanted me to 
bring about an abortion to avoid carrying 
the child to full term. Of course I told 
her I could not do this, but would try and 
tide her over the critical period. I put 
her on treatment with bichloride of mer- 
cury, in one- thirtieth grain doses three times 
per day, through the whole period of ges- 
tation. She then left the city; returning 
some time after she again become pregnant, 
and I treated her in the same way through 
that period of gestation; a perfectly 
healthy child was born and now shows no 
signs whatever of syphilis; the child is 
now five years old. I give the history of 
the man: At that time he gave me the 
history of having contracted syphilis 
twenty years before. This had apparently 
been cured, no further symptoms having 
developed until about two and one-half 
years ago, when he showed signs of 
syphilis in his walk, loss of memory, etc. ; 
he said he could not remember anything. 
I recognized what I thought to be a mani- 
festation of return of the trouble, and put 
him on iodide of potassium. He improved 
very rapidly at first, so much that he dis- 
continued the use of iodide and passed out 
of my notice for a while. Finally he came 
back to me with a return of the trouble, 
and I again gave him iodide of potassium, 
gradually increasing the dose. He again 
improved and left off the medicine 



January 21, 1893. Correspondence. 



95 



entirely. I was hurriedly called to his 
house some time afterward, and found the 
man in convulsions, and he died in about 
four or five hours. His wife told me that he 
had not been taking medicine of any kind 
for about six months. I have since learned 
that he discontinued the use of iodide on 
the statement of the druggist from whom 
he purchased the drug, that he was con- 
suming a dangerous quantity less, (I think 
he was taking about four drachms three 
times per day), and if he did not quit it 
would kill him. 

Dr. J. M. Kay: I have seen a large 
number of cases of ulceration of the 
mucous membrane of the upper respiratory 
passages from syphilis, and must say that 
I believe iodide of potassium does more 
good than anything else. It has been my 
practice to give mercury and iodide separ- 
ately in these cases. I give iodide for an 
express purpose, and continue giving it 
until the desired results are obtained; 
until the ulcerated surfaces heal up. I 
continue the iodide as long as I have any 



local lesion present, then give mercury. I 
will make here a brief report of an interest- 
ing case I saw some time ago. It was a 
case of syphilis in which there was ulcera- 
tion of the mucous membrane of the nose 
with sloughing of the turbinated, and, at 
the same time, a chancre on the penis. 

Dr. J. E. Hays : I have had only a few 
cases of the kind; I believe two in addi- 
tion to the ones reported, since I have 
been practicing medicine. I have 
never given mercury a trial in any tertiary 
lesion, excepting in the last case referred 
to in the paper. I must say, however, 
that iodide of potassium has never failed 
in a single instance. I believe that is the 
best known remedy in removing syphilitic 
infiltrations. I simply gave mercury in 
this case as an experiment, not having 
very much faith in its efficiency. I believe, 
like some authorities, that if mercury 
would destroy the germ of syphilis, if given 
early, we could do away with all these lat- 
ter manifestations, that is, the so-called 
tertiary symptoms. 



CORRESPONDENCE. 



REVIVAL OF "HEATONISM"; HERNIAL INSTITUTES AND SUBCU- 
TANEOUS INJECTION FOR HERNIA. 



Editor Medical and Surgical Re- 
porter : — We have recently seen through 
an exchange, (the New York Medical 
Journal, Jan. 7th, 1893,) that '* Heaton-- 
ism " and rank, downright quackery has 
again invaded the domain of Hernial 
Therapeutics. This time, however, in a 
more bold and defiant manner than 
Heaton ever dreamed of; for he published 
his wonderful (?) cure in the public press 
only. 

In a nutshell, we are told by Dr. Wm. 
C. Kloman, of Baltimore, that a new 
method of treating hernia by the hypoder- 
mic injection of irritant solutions has en- 
abled him to cure chronic old herniae, 
which have been previously irremediable ; 
that the method was equally successful in 
both sexes at the Institute (?) and that it 
was even equal to the cure of strangulated 
hernia. 

Now, the most preposterous assumption, 
in connection with this so called, new nos- 
trum, is the claim that the wonderful dis- 



covery belongs to Dr. Chas. McCanless, of 
Atlanta, Ga. 

This may pass when addressed to those 
who know little or nothing of hernial lit- 
erature ; but to those of us who have, at 
least a rudimentary acquaintance with that 
part of the history of our art, it certainly 
is news. Nevertheless, in all fairness, to 
the memory of Boston's notorious hernial 
quack, we are bound to ask for informa- 
tion and beg to know in what particular 
the new (?) method differs from Heaton's 
injections ? 

Aye ! It not only is Heatonism repro- 
duced as far as technique goes; but it 
smacks further of methods of Heaton in- 
asmuch as it does not state in the article 
above cited, what is employed as an injec- 
tion-menstrum. 

Is it intended, Koch-like, to withhold 
the great secret until its utter worthless- 
ness is shown; or, like Prince Mattei, 
carefully guard its secrecy against the 
whole world ? 



96 



Correspondence. 



Vol. Ixviii 



It is not generally known that Dr. 
Heaton, of Boston, was the first who ever 
employed invagination of the hernial sac, 
and employed subcutaneous injections 
along the inguinal canal on a large scale 
for hernia. And he claimed he could 
cure all reducible hernise. He, however, 
never pretended that he could treat a 
strangulated hernia in this way. The 
whole world stood amazed at his 
wonderful cures (?) — these cases in which a 
patient after spending a month in bed 
got up with his hernia remaining out of 
sight so loug as a truss was worn ; — which 
permitted him time enough to write out a 
testimonial to the doctor. But the old gen- 
tleman was finally prevailed upon to write a 
book or to supply the data for one. This 
he did ; when the whole thing fizzled out and 
the world, at last, saw the secret, that the 
mystery was the talisman, and that the 
whole thing was little else than a piece of 
downright imposition. 

If something has been discovered which 
will cure certain varieties of hernia, by all 
means give the world the benefit of it; 
but don't thrust on us, as a new discov- 
ery, a revamped relic of Boston Quackery. 

Veritas. 



False Neurasthenia. 

Dr. Myrtle writes as follows upon this 
subject : ' ' We may find symptoms in every 
respect similar to those of true neuras- 
thenia, and it will take you all your time 
and patience, as well as tact, to detect the 
sham from the real. If you look back a 
bit, you will find that as a child she 
showed temper; as she grew, she became 
fitful, hysterical, and given to the sulks ; 
craved for sympathy, and exhibited little 
or no sympathy for others. On question- 
ing her, she describes her sufferings in 
forcible language. She can neither eat 
nor sleep; has not an atom of strength; 
suffers from the most dreadful pain, most 
fearful headaches, and frightful spasms, 
and should you suggest any portion of her 
body from her head to her heels, as possi- 
ble exempt from pain; she often resents 
the insinuation, and declares that is the 
very part where she suffers most. While 
she tells you all this in a sort of whine, 
her features don't show indications of any 
agony, and, if you watch her, you will 
find that she overacts her part. Utterly 
indifferent to the anxiety of parents and 



friends, or to the trouble and expense she 
causes, she seemingly finds gratification in 
watching the unwearied efforts of those 
around her in doing their best to comfort 
and help her. While putting on an air 
of the most abject listlessness while you 
look at or speak to her, if you talk to her 
you will learn that she has both eyes and 
ears; if you assist her in any way she 
makes herself as helpless as she can — a 
dead weight. These creatures not only 
deceive every one around them, but in 
time they succeed in deceiving themselves. 
Were it not so, I cannot understand how 
they continue playing such a sorry game 
for so long, and with so much strain and 
fixity of attention, to the exclusion of 
everything else, as I have seen them do. If 
we push our inquiries a little further, we 
generally discover that there is some 
ocliquity of the moral sense; an ungratified 
whim or disappointed affection at the 
bottom." — Ex. 



Thiol in the Treatment of Burns. 

Bidder {Archives fur Rhinische Chir- 
iirige) says that in treating burns a dress- 
ing should be selected which has the 
following qualities: 

(1) Should not require frequent chang- 
ing. 

(2) Eelieve pain. 

(3) Act as a drying substance. 

(4) Harden the new skin. 

(5) Hinder the growth of micro-organ- 
isms which may have gained entrance to 
the wounded parts. 

The remedy which he has found to 
possess all the sequalities is Thiol which 
may be used in two forms, liquid and 
powder. 

In burns of the first and second degree, 
where the blebs are still intact, it is only 
necessary to brush the burned area with 
equal parts of liquid thiol and water and 
cover with wool. At the end of eight 
days the dressing should be changed, and 
again re-applied if the blebs have not 
healed. If the blebs have been ruptured 
and the corium exposed, all loose skin 
should be cut away and the burned area 
carefully cleaned; it should then be 
brushed with liquid thiol, and powdered 
with salicylic or boric acid and then with 
powdered thiol, and the whole covered 
with vaseline, cotton wool, and bandaged. 
As a rule, one or two dressings are neces- 
sary before the wound has healed. — Ex. 



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Saturday, January 21st, 1893. 



EDITORIAL. 



THE QUARANTINE PROBLEM. 



There is always much gained when an 
important measure reaches the point of 
serious discussion. There is then hope for 
common sense conclusions. The discus- 
sion of the very important question of a 
National Quarantine is taking practical 
form in the halls of our National Congress, 
and there is an assured promise that a 
measure, bearing the ear marks of 
practical statesmanship, will be adopted. 

The question is not one limited within 
the corporate lines of any city or the 
bounds of any one state. It is one 
broader even than our national domain. It 
should be treated nationally, distributing 
the burden of an effective quarantine over 
the entire people, thus mitigating feat- 
ures that would otherwise prove oppressive 
to distinct communities. 

The difficulty of building efficient bar- 
riers against Asiatic cholera is recognized 
by all scientific men. The inefficiency of 
local quarantine was thoroughly demon- 
strated last summer. The quarantine at 
New York was as efficient as it was possi- 
ble to make it with inadequate means, im- 
perfect methods and the discreditable jeal- 



ousies of officials, yet it did not keep the 
cholera out of New York City. There 
may be pestilence in politics but there are 
no politics in pestilence. The opposition 
of local or city health authorities to those 
of the Federal quarantine was forcibly 
illustrated by many little episodes in New 
York's experience. 

A notable fact was, that after the issue 
of the President's proclamation of national 
quarantine, no passenger vessel brought a 
case of cholera to this country. It had 
the good effect of enforcing more care 
abroad. It was a warning that crossed the 
Atlantic — a notice to all passenger carrying 
steamships that American ports were closed 
to all vessels carrying pestilence and that 
they would remain closed until all danger 
was passed. 

There is a provision of our Federal Con- 
stitution which imposes upon Congress one 
of its highest and most sacred duties, that 
is, to 4 4 provide for the common defence 
and general welfare of the United States." 
We take it that the general health comes 
within the provision for the 44 general wel- 
fare," and that this clause gives the power 



98 



Editorial 



Vol. lxviii 



to establish a system of rigorous, and as 
far as human measures are possible, effec- 
tive quarantine, 

Dr. Watson, chairman of the Inter- 
national Quarantine Committee, reported 
that there is not a single port on the 
North Atlantic coast that is supplied with 
all the requisite means and methods of 
modern maritime sanitary science. He 
gave to Philadelphia the credit of being 
the best supplied of any port in the 
country. 

Certainly our experiences, modern 
science, the stimulus of recent menaces of 
pestilence, have substituted greatly im- 
proved for antiquated methods, — importers 
and reporters to the contrary notwith- 
standing. 

The question of the further improve- 
ment of methods and appliances and their 
efficient application is the one that at 
present most concerns American com- 
munities. 

Eeason and humanity dictate that we 
use every device and method approved by 
science and experience in protecting the 
public health. Our precautions should 
be taken before we are confronted by con- 
ditions of terrible peril; they will be too 
late when pestilence has secured a foot- 
hold. 

A double quarantine is not objection- 
able. To approach completeness it should 
be both local and national, with the hearty 
and vigorous cooperation of all authorities 
to whom the work may be intrusted. 

With a coast as extended as ours, cases will 
be likely to break through however vigor- 
ous the quarantine may be. The Federal 
authorities will have in their possession the 
better means and facilities of enforcing 
essential measures, and will command more 
respect than can or will local authorities. 
This respect would the more specially be 
felt abroad and would further have the 
good effect of keeping away from our 
shores a very undesirable class of people. 
Local resources are of ten limited, and there 



is a lack of the implements or plants for 
adequate and quick disinfection. 

The effective guarding of the country 
against epidemics necessarily involves 
many risks and hardships. The distress 
of a stringent quarantine must, in the 
very nature of things, be seriously felt in 
all trade and commercial centres. This 
fact presses the importance of placing the 
discharge of all the duties of quarantine 
authority in the hands only of men of the 
highest character and intelligence; men 
wise, quick and prompt in the discharge 
of duty, and that without fear or favor; 
men above the motive of selfishness, of 
local or trade jealousies. Neither the in- 
terest of the individual, nor of any class of 
individuals, nor of any one or more com- 
munities should be allowed to stand in 
the way of the " general welfare." 

While there exists no reason for undue 
alarm, neglect to take precautions against 
the possible visit of an epidemic would be 
crime. Philadelphia has had three visita- 
tions of Asiatic cholera, 1832, 1849, 1866, 
and has no assurance of exemption in the 
future. The responsibility vesting upon 
our local authorities cannot by them be 
over estimated. 

Cleanliness is the one great foe of 
cholera. Filth has many lurking places 
and should be routed out and destroyed. 
Every disease breeding hole and corner 
should be disinfected. Active practition- 
ers of medicine can exercise a potent in- 
fluence in this line. They have been 
made painfully familiar with the 
causes of many of the terrors with 
which they have to deal — they know where 
lurks the fruitful source of pestilence, 
and, where they will to exercise it, they have 
an effective voice in its removal. Dili- 
gent efforts in the way of sanitation should 
be made in every city, town and village. 
In our own city, health, good morals, 
great trade and commercial interests are 
involved, and cleanliness will do as much, 



January 81, 1893. Editorial. 



99 



if not more for us, than quarantine with 
its embarrassing restrictions. 

It has been estimated that a complete 
quarantine will eliminate seventy per cent, 
of the probability of the introduction of 
cholera. Certainly the other thirty per 
cent, can be prevented by cleanliness and 
the practice of the best known principles 
of preventative medical science. 

London, the great commercial centre of 
Europe, toward which tend all the roads 
of the old world, had but ten deaths from 
cholera in 1892. In our own city the 
deaths from diphtheria have doubled and 
quadrupled that number in one week. 
Our house cleaning will keep out the foes 
of public health. 

The Senate Bill places the matter of 
national quarantine where, under existing 
conditions, it should be. There is no 
more intelligent, scholarly and scientific 
a set of men in the country than the medi- 
cal authorities in the marine service. 

The following from the Report of the 
Senate Committee in epidemic diseases, is 
worthy of thoughtful reading : 

''The committee is satisfied that an effec- 
tive and uniform system of quarantine 
regulations vigorously enforced at all ports 
and places having commercial intercourse 
with foreign countries is absolutely neces- 
sary as the only means of preventing the 
importation of contagious and infectious 
disease into this country from other 
countries, and that a perfect and uniform 
system is equally necessary to prevent the 
importation of such diseases into one 
State from another. 

Some of the States have adopted systems 
of quarantine regulation which, in the 
opinion of the committee, are sufficient, 
so far as treatment at the port of entry is 
concerned ; but many others have no quar- 
antine regulations whatever, and if a single 
gate is left open to the introduction of 
such diseases the whole country may suffer 
the disastrous consequence of fatal epi- 
demics. 



Scientific investigation has asserted that 
neither yellow fever nor cholera origin- 
ates in this country, but that if either is 
imported, under certain atmospheric con- 
ditions they will take root and spread with 
disastrous rapidity and fatality. 

The most important of all considera- 
tions is to keep them out, and in the 
opinion of the committee the only means 
of effectually preventing their importation 
is a thorough system of national quaran- 
tine, which shall be uniform and enforced 
with vigor at every point of intercourse 
with foreign nations, and equally uniform 
and equally enforced as between States. 

State quarantine authorities have been 
jealous of any interference by national au- 
thority with their quarantine regulations, 
and those of New York and New Orleans 
have heretofore steadily opposed any na- 
tional control of the subject. 

The quarantine regulations of these 
States give a large revenue to these States 
or to their boards of health, and for that 
reason, if for no other, they may be ex- 
pected to oppose national control. 

Now, however perfect their systems of 
regulations and the systems of other States 
may be, they are but the systems of a 
small proportion of forty-four States. 

The forty-four States need, demand, 
and&re entitled to protection from this 
importation of disease. 

The eighth section of article one of the 
Constitution of the United States provides 
that — 

Congress shall have power to regulate commerce with 
foreign nations and among the several States and with 
the Indian tribes. 

The regulations proposed by this bill 
are strictly regulations of foreign and in- 
terstate commerce and nothing more. 

The transportation of a person or any 
article of merchandise from any foreign 
country to this country, or from this to 
any foreign country, is an act of ' ' com- 
merce with foreign nations," and the trans- 
portation of persons or property from one 



100 



Editorial. 



Vol. lxviii 



State to another is an act of " commerce merce with foreign nations and among the 
among the States." several States" as to strip it of contagion 

This bill proposes to so ie regulate com- and infection. 



NATIONAL QUAKANTINE. 



The Quarantine Bill passed by the 
United States Senate, Tuesday, January 
10th, consists of ten sections of carefully 
framed legislation which seem to us to pro- 
vide reasonable security for the public 
health from the invasions of infectious or 
contagious diseases. It provides for medical 
inspection of all vessels both at the port of 
departure and that of entry, and requires 
from each a clean bill of health, thereby pro- 
tecting the country against infection from 
abroad. It authorizes the establishment 
of quarantine as between the States, so 
that if such disease should effect a land- 



ing, its progress may be stayed. It abol- 
ishes the National Board of Health, and 
puts the whole subject under the control 
of the President of the United States, 
with ample power for needful details in 
the hands of his Subordinate, the Secre- 
tary of the Treasury, thereby making 
prompt action possible in any emergency. 
It provides for adequate penalties for the 
violation of the law or of any regulations 
established under it; and appropriates 
$1,000,000 to carry its provisions into 
effect, thereby, putting power behind all 
its provisions. 



RESUME OF MEDICAL PEACTIOE ACTS IN THE DIFFERENT 
STATES AND TERRITORIES. 



In response to numerous requests we 
give the following, taken from Medi- 
cal Education, etc., published by the 
Illinois State Board of Health, 1891. 

Alabama. — Examination by the State Board of Ex- 
aminers, or by a County Board of Examiners. Law 
passed in 1877. 

Arizona. — Register diploma with County Recorder. 
Passed in 1881. 

Arkansas. — Registration of diploma or examination 
by the State or a County Board of Examiners (latter 
inoperative). Law passed 1881. 

California. — Certificate on diploma from a college 
in "good standing" or examination by one of the three 
Boards of Examiners. Passed in 1876. 

Colorado. — Certificate on diploma of college in " good 
standing " or examination by the State Board of Medi- 
cal Examiners. Passed in 1881. 

Connecticut. — No law except against advertising 
itinerants. 

Delaware. — Registration of diploma in a County 
Clerk's office. Passed in 1883. 

District of Columbia. — Endorsement of diploma or 
examination by committee of the District Medical 
Society (practically inoperative). Passed in 1838. 

Florida. — Examination by one of the State or Dis- 
trict Boards of Medical Examiners. Passed in 1884, 
1889. 

Georgia. — Registration of diploma in the office of 
the Clerk of the Superior Court. Passed in 1881. 



Idaho. — Record diploma at county seat. Passed in 
1887. 

Illinois. — Certificate on diploma from college "in 
good standing " or examination before the State Board 
of Health. Passed in 1877, 1887. 

Indiana. — Registration of diploma in County Clerk's 
office. Passed 1885. 

Indian Territory. — (a) Cherokee Nation: Examina- 
tion by the Board of Examiners of the Nation. Passed 
1878. (b) Choctaw Nation: Certificate on diploma or 
examination by the Board of Examiners of the Nation, 
(c) Creek Nation: No law. 

Iowa. — Certificate on diploma from college ''in good 
standing" or examination by the State Board of Medi- 
cal Examiners. Passed 1886. 

Kansas. — No law. 

Kentucky. — Ten years' practice, or registration and 
endorsement of diploma of a legally chartered college 
by Secretary of the State Board of Health. Passed 
1874, 1888, 1890. 

Louis ana. — Recording diploma before County Clerk 
or Justice of the Peace after endorsement of same by 
State Board of Health, which is "required to certify 
to the diploma of any medical institution of credit and 
respectability without regard to its system of therapeu- 
tics." Passed 1882, 1889. 

Maine. — No law. 

Maryland. — Verification of diploma of "college in 
good standing," or examination by State Board of 
Health (law inoperative) . Passed 1888. 

Massachusetts. — No law. 

Michigan. — Record diploma in County Clerk's office. 
Passed 1883. 



January 21, 1893. 



Translations. 



101 



Minnesota. — Examination by State Board of Medi- 
cal Examiners. Passed 1883, 1887. 

Mississippi. — Examination by a County Board of 
Medical Censors. Passed 1882. 

Missouri. — Certificate on diploma from college in 
"good standing" or examination by State Board of 
Medical Examiners. Passed 1883. 

Montana, — Ten years'practice, certificate on diploma 
from a college "in good standing " or examination by 
State Board of Medical Examiners. Passed 1889. 

Nebraska. — Register in the office of the County 
Clerk. Passed 1881, 1883. 

Nevada. — Register diploma before the County Re- 
corder. Passed 1875. 

New Hampshire. — License from the Board of Censors 
of Medical Society. 

New Jersey. — Examination by the State Board of 
Medical Examiners. Passedl880, 1888, 1890. 

New Mexico. — Endorsement of diploma or examina- 
tion by Territorial Board of Examiners. Passed 1882. 

New York. — Examination by one of the State 
Boards of Examiners, after September 1, 1891. En- 
dorsement of diploma until September 1, 1891. Law 
passed 1880, 1888, 1890. 

North Carolina. — Examination by the State Board 
of Medical Examiners. Passed 1859, 1885. 

North Dakota. — Examination by the State Board 
of Medical Examiners. Passed 1890. 

Ohio. — Law inoperative. 

Oregon. — Certificate on diploma from a college " in 
good standing " or examination by the State Board of 
Medical Examiners. Passed 1889. 

Pennsylvania. — Registration of diploma before 
County Prothonotary after endorsement (of diploma 
from college outside of State) by some Medical College 
within the State. Passed 1881. 

Rhode Island. — No law. 



South Carolina. — Examination by the State Board 
of Medical Examiners. Passed 1881, 1888. 

South Dakota. — Certificate on diploma, or examina- 
tion by the Territorial Board of Health. Territorial 
law 1884. 

Tennessee.— Registration after certificate on diploma 
of college "in good standing "or examination by 
State Board of Medical Examiners. Passed 1889. 

Texas. — Registration after endorsement of diploma, 
or examination by a District Board of Examiners 
(practically inoperative). Passed 1876, 1879. 

Utah. — No law. (Recent enactment requiring exam- 
ination not at hand. — Ed.) 

Vermont. — Registration after endorsement of 
diploma, or examination by a Board of Medical Censors 
appointed by either State Medical Society. Passed 
1880. 

Virginia. — Examination by State Medical Examin- 
ing Board. Passed 1884, 1888. 

Washington. — Examination by State Medical Ex- 
amining Board. Passed 1890. 

"West Virginia. — Certificate on diploma of " repu- 
table" college, or examination by the State Board of 
Health. Passed 1882. 

Wisconsin. — Examination or endorsement of diploma 
by the censors of any State or County Society. Laws 
of 1878, 1881. 

Wyoming. — File record of diploma with Registrar of 
Deeds. Passed 1886. 



In Minnesota, Montana, North Dakota and Washing- 
ton every applicant for license to practice must have at- 
tended three courses of lectures. The same will be re- 
quired by the California Boards after April 1, 1891; the 
Colorado Board after July 1, 1893; by the Illinois and 
Iowa Boards after the session of 1890-91 and by the 
Boards of Examiners of New York after September 1, 
1891. There will probably be three more State Examin- 
ing Boards in the next year. 



TRANSLATIONS. 

GONORRHEAL INFECTION— MODES OF EXTENSION. 



There is no doubt that blennorrhoea in 
women is of more frequent occurrence 
than is generally accepted and that its re- 
sults are more extensive than was former- 
ly taught. It has been shown that blen- 
norrhoea in the female can involve the en- 
tire genital tract — the uterus, tubes, ovaries 
and even the neighboring peritoneum may 
be attacked by acute inflammation. It has 
also been shown that women in the first 
days of their married life have been in- 
fected by their husbands, who, since they 
had no discharge, had been declared by 
their physicians to be cured, or who mar- 
ried when they themselves felt satisfied 
they were no longer diseased. In this 
manner many young women begin to suf- 
fer more or less from the early days after 

"^Translated for Medical and Surgical Reporter. 




marriage to the end of their natural life. 
Menstruation becomes abnormal; the ut- 
erus and its adnexa undergo inflammatory 
changes; the wife may abort frequently or 
remain sterile, or she may bear one or two 
children, and the puerperium may be com- 
plicated with inflammation. 

A large number of such unfortunate 
women present themselves to us and often 
try our patience to the utmost. They fre- 
quent the various sanitaria and markedly 
increase the percentage of the nervous 
hysterical women. Their sterility, from 
the social standpoint, is really deplorable, 
since large families die out and the popu- 
lation is much influenced. That women 
so affected can still become pregnant no 
one doubts, but that blennorrhoea pro- 
duces pathological changes in the uterus, 



102 



Translations. 



Vol. lxviii 



tubes and ovaries has been demonstrated 
also beyond a doubt. 

In relation to the diagnosis and course 
of this disease the author differs from 
Zweifel, Saenger, Fritsch and others. It 
is remarkable that these eminent men 
have, by various theses, explained the ori- 
gin of blennorrhoea as accepted to-day in 
almost the same words as those of Nceg- 
gerrath; and we to-day understand the 
etiology of the microbes of blennorrhoea. 
According to their investigations, blennor- 
rhoea in the male will exist a long time 
after infection without any symptoms be- 
ing present. This is termed latent blen- 
norrhoea and will induce in the female also 
a latant blennorrhoea, which may not pro- 
duce any symptoms for months, oft times 
none., until marked disease of the uterus 
and its appendages attracts the attention 
of the physician. In such the secretions 
show no gonococci. 

Dr. Feleki contends that latent blen- 
norrhoea exists neither in the male or 
female, but that the male may have an 
urethritis of either a contagions, acute, or 
chronic character, or no blennorrhoea; or 
he may have, resulting from an old blen- 
norrhoea, the pathological changes which 
cause the urethritis. 

Inflammation of the urinary tracts of an 
infective character in the male, even if of 
some years standing and showing no dis- 
charge, will produce in the female a 
typical, not latent, attack of blennorrhoea. 
The definite diagnosis of blennorrhoea in 
chronic cases can only be secured when 
gonococci are found in the secretions or 
urine. 

In the inital stages of blennorrhoea, 
gonococci are always found; and in the 
chronic stages, they are always present, 
except in those cases where the catarrh is 
no longer present, but pathological changes 
can be thoroughly demonstrated, or where 
other affections are present which change 
the character or cause of the secretion. 

The author having studied this subject 
for several years has arrived at the follow- 
ing conclusions: 

First. Chronic blennorrhoea in the male, 
even if no other symptoms are present, 
has the occasional appearance of gonococci 
in the urine, and will produce in the 
female a typical attack of blennorrhoea. 

Second. If the secretion from the 
urinary passages of the male contains no 
gonococci, there will be no direct attack of 
blennorrhoea in the female. 



Lastly the author calls attention to an 
affection which has received very little 
study of late, namely, pseudo-gonorrhaea. 
It is known that an infectious urethritis can 
exist in the male, the secretion of which 
will show no gonococci throughout its 
course. It is questionable whether this 
appears in the female. As facts directing 
the attention to this point the author cites 
Ophthalmo - Blennorrhoea Neonatorum. 
Investigation has shown that this disease 
from its etiology and course could be 
divided into two groups. In the group 
which could be classed the severer, the 
gonococci could be found in the secretion, 
while in the cases of lighter form the 
microbe could not be found. The 
question naturally arises if in these lighter 
forms the cause was that of pseudo- 
gonorrhoea. — C Wiener arztl. Centr. — A uz.) 



Vermiform Appendix Containing a Foreign 
Body Found in a Hernia. 

H. Schmidt (Miinch Med. Wochen., 
1892). The vermiform appendix is rarely 
found within a hernia, but few cases hav- 
ing ever been recorded in medical litera- 
ture. The author reports one case. A 
woman aged 53, who had a right inguinal 
hernia of recent origin, which became in- 
flamed, and after a few weeks opened and 
discharged blood, pus, and fecal matter. 
During the operation Schmidt found a 
hernia sac in which was caught a vermi- 
form appendix — along the side of this a 
sound could be readily passed into the ab- 
dominal cavity. 

The hernial sac was removed and its 
opening closed. Complete recovery. 
Close examination of the removed vermi- 
form appendix disclosed the presence of a 
large black pin. 



Personal Experience in the Operative Treat- 
ment of Ruptured Tubal Pregnancy. 

( Berlin Klin. Wochen, 1892. ) Gusserow 
gives a report of twenty cases operated 
upon by him. In thirteen of these there 
had been no premonitory symptoms pre- 
vious to the collapse brought on by in- 
ternal hemorrhages, while in seven there 
had been a formation of an hematocele 
previous to the dangerous hemorrhage 
which called for operation. 

In the first group of thirteen there were 
two deaths. One due to collapse, the 
operator having been called too late. The 



January 21, 1893. 



Abstracts. 



103 



other died thirty days after from chronic 
disease of the kidneys. 

In the second group of seven cases 
there was one death. 

Gusserow advises, as a result of his ex- 
perience, operation for all cases of ruptured 
tubal pregnancy. He would not hesitate 
to have a patient in collapse taken to the 
hospital for operation. Prognosis is 
always more favorable the earlier the cases 
are recognized and operated on. 

In closing his remarks he expresses him- 
self in favor of operation on such cases in 



which the diagnosis is clear, previous to 
rupture, but adds that sure diagnoses are 
ofttimes difficult, since a small ovarian 
cystoma lying close to the uterus might be 
taken for tubal pregnancy. In such cases 
he advised placing the patient under care- 
ful and close observation, absolute rest 
and expectant treatment, in order to 
determine if the uterus or the tumor in- 
creases in size. It is of yet greater diffi- 
culty to determine whether the ovum in 
the tube still lives or not : a question which 
materially influences the operator in 
deciding upon prompt interference. 



ABSTRACTS. 

THE ADMINISTRATION OF OHLOKOFOEM, AND ITS DANGERS. 



In an address before the Inter- colonial 
Medical Congress of Australasia, Dr. 
James Robertson, President of the Section 
in Medicine, says : 

The vital importance of the subject, 
the frequent occurrence of fatalities, 
and the conclusions arrived at by 
the Hyderabad Chloroform Commission, 
which he regards as fraught with danger, 
induced hirn to select this subject. 

The administration of chloroform — the 
most potent and valuable of anaesthetics- 
is to be regarded as one of the most re- 
sponsible duties devolving on a medical 
man ; seeing that the life of a human being- 
is at stake, and its sudden termination is 
dependent, in a great measure, on his 
care and vigilant circumspection. Not- 
withstanding the numerous attestations in 
favor of chloroform, many in doubt and 
distrust are adopting the use of ether. 

No anaesthetic can be said to be abso- 
lutely free from danger, but with judicious 
care and caution the risk may be reduced 
to a minimum. Chloroform has been 
well described by Dr. Lauder Brunton, as 
being " like a sharp knife in the hands of 
the surgeon, as compared with a blunt 
one. It is more efficient for good, if 
properly handled ; it is more powerful for 
evil, if misused." Ether, it must be 
allowed, is less dangerous than chloroform, 
in not causing so much depression of the 
heart's action, but it is unpleasant, irrita- 
ting to the air-passages, cannot be used 
under certain circumstances or in every 
case. 



Chloroform maintains supremacy as the 
most " pleasant, speedy, and efficient" 
anaesthetic, requiring no special apparatus, 
suitable in every case fit for operation, and 
safe when given with judicious care. Its 
advantages are such, that it has been 
generally adopted in preference to all other 
anaesthetics, and is still regarded with most 
favor. 

In 1888, and again in 1889, Commis- 
sions were appointed by His Highness the 
Nizam of Hyderabad, at the request of 
Surgeon-Major Lawrie, to investigate the 
action of chloroform. The philanthropy 
of His Highness, in liberally supplying 
funds for the experiments, and the ex- 
penses of an expert sent from England, 
cannot be too highly appreciated, the 
laudable object of the commission being, 
in the words of the Nizam, " to save peo- 
ple's lives." The commission, after the 
sacrifice of hecatombs of dogs and mon- 
keys, arrived at the conclusions, that, " in 
every case where chloroform was pushed, 
the respiration stopped before the heart," 
and that " the administrator should be 
guided as to the effect entirely by the res- 
piration." The numerous experiments 
and their record manifest careful and la- 
borious investigation, and merit the 
thanks of the profession, but the conclu- 
sions arrived at cannot be accepted as 
applicable to human subjects. The result 
of the experiments has been to direct 
attention to a subject of vast importance, 
and to arouse inquiry, which cannot be 
otherwise than beneficial. 



104 



Abstracts. 



Vol. lxviii 



My experience of the administration of 
chloroform extends from the year of its 
introduction by Professor Simpson, 1847, 
the year in which I myself commenced 
practice. For nearly forty-five years I 
have exhibited that anaesthetic in many 
thousand cases, often in prolonged opera- 
tions, and never with fatal consequences. 
I refrain from reducing the number to 
figures, as I cannot even give a close ap- 
proximation to it. In not a few instances, 
alarming and even dangerous symptoms 
have presented themselves, and have 
strongly impressed me with the risk of 
trusting alone to respiration as the index 
of danger. I have watched both pulse 
and respiration, and ultimately came to 
regard the state of the pulse as the first 
signal of danger. I have no new experi- 
ments to lay before you, but I shall en- 
deavor to demonstrate, from the experi- 
ments of others, and from clinical obser- 
vation and experience, that the state of 
the pulse is not of less importance than 
the state of respiration, as an indication 
of danger in the administration of chloro- 
form; that it is, indeed, the earliest and 
most significant danger signal. 

Different individuals are differently af- 
fected by chloroform inhalation, and this 
may be accounted for by constitutional 
peculiarities. Some inhale quietly, and 
are speedily brought under its influence; 
some become excited, and toss their ex- 
tremities about; while others resist and 
struggle violently. This, however, may 
be due to the mode of administration. 

It is very generally urged, that the 
pulse should not be taken as any guide in 
the administration of chloroform; that 
the respiration alone demands attention. 
This contention seems to be strengthened 
by the Report of the Hyderabad Commis- 
sion, to the effect that, in animals respira- 
tion always stopped before the heart, and 
that all danger can be averted by attend- 
ing to the respiration alone. Although I 
do not decry the results of experiments 
on the lower animals, inasmuch as they 
afford most valuable indications, I object 
to hard and fast lines being drawn, and 
hesitate to accept the dictum, "that the 
effects of chloroform are identical in the 
lower animals and in the human subject." 
It is well known that the effects of vari- 
ous drugs differ much, more especially of 
narcotics, when administrated to the 
lower animals and to man. The lower 



animals are not capable of being influenced 
by the same feelings and emotions as man, 
and, according to the testimony of the 
Hyderabad Chloroform Commission, oper- 
ations liable to produce shock and syncope 
in man, were singularly devoid of effect 
in dogs. The effects of chloroform are 
not uniform in different human indi- 
viduals, even when administered in the 
same way, and in certain definite propor- 
tions, or even in the same individuals at 
different times. According to the experi- 
ments of the Hyderabad Chloroform Com- 
mission, respiration always fails before 
the circulation, and there is no such thing 
as chloroform syncope. Experiments on 
animals reported by other Commissions, 
"the Royal Medico- Chirurgical Society's 
Committee of Inquiry," and " the British 
Medical Association's Committee on Anaes- 
thetics," negative to some extent the con- 
clusions of the Hyderabad Chloroform 
Commission, showing that, while in most 
cases the respiration stopped before the 
heart, sometimes both respiration and the 
heart's action failed simultaneously, and 
sometimes the heart failed before respira- 
tion. The testimony of other observers 
is not less adverse. Dr. Snow, forty years 
ago, showed that, in animals killed by 
chloroform inhalation, when the air con- 
tained not more than 5 per cent, of vapor, 
the heart continued to pulsate when res- 
piration had ceased. When the air con- 
tained 10 per cent, and upwards, death 
took place more speedily, respiration and 
circulation ceasing at the same time, there 
being sufficient vapor in the lungs at the 
moment the breathing stopped to paralyse 
the heart, as soon as it was absorbed and 
added to that already in the blood. This, 
he terms its cumulative property, when 
the effects of chloroform increase after 
discontinuance of inhalation. 

It appears that the most immediate ef- 
fect of chloroform on the heart, or on the 
respiration, was influenced by the more or 
less concentrated state in which it was 
administered. But, even were it proved 
that chloroform invariably causes death in 
animals by paralysing the respiration, we 
have the most positive evidence that fail- 
ure of the heart's action is the most fre- 
quent cause of death in man. An over- 
whelming amount of evidence has ac- 
cumulated, and still continues to accumu- 
late, since the first recorded death from 
chloroform in 1848, to the effect that the 



January 31, 1893. 



Abstracts. 



105 



occurrence of death in the human subject 
is almost invariably due to primary failure 
of the heart, or syncope. Such is, indeed, 
the principal source of danger, and it is a 
remarkable circumstance that a diversity 
of opinion should exist in regard to a 
■question capable of definite solution. 

Clinical experience goes to prove that 
death from failure of the heart is the 
usual source of danger in the human sub- 
ject, and is especially liable to occur when 
the vapour of chloroform is inhaled in a 
concentrated form, or insufficiently diluted 
with air. The records of the numerous 
fatal cases reported in the various medical 
periodicals conclusively attest that death 
from syncope is the most common termin- 
ation in man. For not only have the 
deaths been attributed to failure of the 
heart, but in cases where post-mortem ex- 
aminations were made, such lesions have 
been described as 1 ' fatty heart," ' 'flabby 
heart" "heart dilated," &c, &c. It is well 
known, however, that in many, if not in 
most, cases, where death has supervened, no 
lesion of heart, or of any other organ, has 
been discovered — that, in fact, the syn- 
cope was due to chloroform poisoning. 

THE INDICATIONS AND SOURCES OF DAN- 
GER OF CHLOROFORM NARCOSIS. 

The period of greatest danger appears 
to be at the commencement of inhalation, 
before the patient has been thoroughly 
brought under its influence, and not dur- 
ing the progress of even a prolonged oper- 
ation. It has been stated that the danger 
of failure of the heart's action, from the 
depressing effect of chloroform, depends 
•on, and is in proportion to the length of 
time of inhalation, and consequently of 
the operation. This, however, is not the 
case. If chloroform is given sufficiently 
diluted with fresh air, and respiration 
continues normal, the vapour of chloro- 
form is exhaled, as well as inhaled, and 
the blood does not become so saturated, 
as to endanger the heart. The danger is, 
in a great measure, dependent on the 
amount or degree of concentration of the 
vapour inhaled ; as the vapour, if inhaled 
insufficiently diluted with air, affects the 
heart more directly, and may lead to sud- 
den paralysis of that organ. 

The immediate causes of death in 
chloroform toxaemia, are syncope, and 
apnoea. In the large majority of cases, 
death takes place from sudden syncope in 



the human subject, due to paralysis of the 
heart. 

Death may also result from syncope 
brought about by the combined effects of 
sickness of stomach, and the depressing 
influence of chloroform on the heart. 
This stomach sickness, or nausea, has 
been stated "to be only unpleasant and 
inconvenient, desirable to avoid, but not 
attended with any danger." It has, how- 
ever, proved a real danger, inasmuch as in 
not a few cases, suffocation has been in- 
duced by food being drawn into the glottis 
during the effort of vomiting. But apart 
from this, when there is no food in the 
stomach, there is, in my opinion, a real 
danger attending sickness, unless the pulse 
is watched. I have frequently observed 
the pulse became slow and weak, and the 
lips blanched, and have thus been led to 
withdraw the chloroform instantly, and 
then the faintness was followed by vomit- 
ing. If, instead of withdrawing it, chloro- 
form had been pressed, as I have some- 
where seen advocated "to stop the con- 
tractions of the stomach," it might have 
resulted in stoppage of the heart's action. 
I am strongly of opinion that, when a 
patient is in a fainting condition, even a 
small dose of chloroform may so affect the 
heart, as to cause complete cessation of its 
action, and that the pulse gives the first 
indication of danger, the first warning, 
respiration if at all, being but little influ- 
enced. 

Deaths from apnoea are only occasionally 
met with. They arise from spasms of the 
glottis and diaphragm obstructing the res- 
piration, and are sometimes attributed to 
reflex action in some operations ("ligaturing 
hemorrhoids, etc.), when the patient is 
not thoroughly anaesthetised. Apnoea is 
sometimes attributed to the tongue falling 
back and occluding the glottis, when a 
patient is lying on the back under the in- 
fluence of chloroform narcosis; from this 
source, I have never seen any cause for 
alarm. 

PRECAUTIONS TO BE OBSERVED IN ADMIN- 
ISTERING CHLOROFORM. 

It will be readily admitted that the 
chloroformist should give his whole atten- 
tion to his patient; should see that the 
chloroform is pure; that the patient has 
not recently eaten food; that he is placed 
in the recumbent position, or in such a 
position as not to obstruct respiration, all 



106 



Abstracts. 



Vol. lxviii 



articles of clothing being loose about the 
neck, chest, and abdomen. I regard the 
u se of table-napkin or towel folded in the 
f orm of a cone, with or without an aper- 
ture at the apex, such as was originally 
proposed by Professor Simpson, as well 
adapted for the purpose. One-half to a 
drachm of chloroform should be sprinkled 
on the napkin as required, so as not to 
moisten the border likely to come in con- 
tact with the face. 

In commencing inhalation, always allow 
sufficient space for the free admission of 
atmospheric air, so that the vapour may 
be diluted, and its effect may be gradually 
produced, so as to avoid exciting cough or 
struggling. Allowance should be made 
in the warm season of the year for the ef- 
fect of temperature in rendering chloro- 
form more volatile, and thus causing the 
air to become more saturated with the va- 
pour. Patients should be gradually 
brought under the influence of chloroform 
until its full effect is produced, and then 
very little chloroform will be required to 
maintain insensibility. The vapour may 
be diluted with more air, by withdrawing 
the inhaler to some extent, or inhalation 
may be intermitted for two or three in- 
spirations occasionally. 

The state of the pulse should be care- 
fully watched ; it gives the first indications 
of danger. When the pulse becomes weak 
and slow, perhaps irregular and intermit- 
tent, fresh air should be freely ad mitted ; 
when, moreover, respiration becomes shal- 
low and feeble, perhaps stertorous, the in- 
haler should be withdrawn altogether for 
a short time. In prolonged operations, 
special care should be taken that the 
vapour inspired is sufficiently diluted with 
fresh air, so as to guard against sudden 
syncope, the most frequent cause of a fatal 
termination in the human subject. 

MEASURES TO BE ADOPTED IN SUSPENDED 
ANIMATION FROM CHLOROFORM. 

The head should be lowered and feet 
elevated, and artificial respiration com- 
menced without delay, fresh air being 
freely admitted, and any obstruction to 
respiration removed. Nelaton's plan of 
inverting the body, and artificial respira- 
tion, are without doubt most conducive to 
resuscitation in chloroform poisoning. By 
this means the blood will gravitate towards 
the head, and the action of the heart may 
be roused to contract, and send a supply 



of blood to the brain and medulla, so as to 
stimulate the cardiac and respiratory cen- 
tres. 

No successful issue has followed the 
employment of galvanism that I have 
heard of; and certainly, not more benefit 
can be expected to result from nitrite of 
amyl inhalation, which causes dilatation of 
the peripheral blood-vessels, a condition 
already existing to the fullest extent, and 
which it is desired to remedy. Nitrite of 
amyl is therefore contra-indicated. The 
injection of ether subcutaneously, or of 
ether and strychnine, is more rational, 
and likely to prove of benefit, artificial 
respiration being kept up. Mr. Bader 
(Ophthalmic Surgeon, G-uy's Hospital) 
states that, "out of a large number of cases 
(3224), some presented serious symptoms, 
becoming blue in the face, with stertorous 
breathing and irregular pulse, seven be- 
came pale suddenly, with respiration and 
pulse stopping. In all these cases the 
chloroform was removed, and the patient 
slowly and gently turned to the left side. 
Patients recover rapidly when placed on 
the left side, due, it may be, to the sup- 
port given to the heart, or to a change in 
the position of the tongue." This, he 
states, is the sole means adopted at Guy's 
for the last six years. 

The Marshall Hall method failing to 
restore animation in a desperate case, Dr. 
Prince, (Illinois State Medical Society, 
1891,), adopted a new method of resusci- 
tation based on Nelaton's method of in- 
verting the body : — He seized the patient, 
a boy of 14 years, by the ankles, his knees 
being flexed over the doctor's shoulders, 
with head and arms dangling toward to 
floor. In that position he subjected him 
to "double-quick motion around the 
operating-room, and after about three 
minutes, the sounds of restored respira- 
tion were heard." The doctor further 
states: — "Each step was taken with a 
springy motion, by which the weight of 
the intestines resting upon the diaphragm 
would be alternately applied and removed 
with the tread, the effect of which would 
be calculated to stimulate the heart and 
force the blood along its channels, while 
the air was simultaneously changed in the 
lungs." Three other cases are related, 
one a young woman of great weight (140 
lb.), another a physician, who were sub- 
jected to similar treatment with alike 
favorable results. As it appears that in 



January 21, 1893. 



Abstracts. 



107 



two of the four cases reported, the Mar- 
shall Hall method of restoring animation 
was had recourse to, without success, be- 
fore adopting the method described, the 
success of the new method appears to be 
the more remarkable,, seeing a considerable 
time (not noted) was said to have elapsed 
before it was commenced. That fact 
caused me to hesitate in crediting the re- 
port, but the circumstantiality in detail, 
the names and dates, etc. , forbade my en- 



tertaining any doubt of its genuineness. 

From the preceding remarks, it will be 
apparent, that, in my opinion, chloroform 
is the best anaesthetic yet discovered ; that 
it is quite safe if judiciously administered, 
and its action closely watched; that the 
pulse, and not the respiration, gives the 
first indication of danger, and ought, 
therefore, not only to be constantly under 
the fingers, but to occupy the attention. 
— Australian Med. Jour. 



APPENDICITIS : — MEDICAL AND SURGICAL MANAGEMENT. 



At the September meeting of the Mis- 
souri Valley Medical Society, Dr. A. F. 
Jonas, read a most interesting paper on 
the above subject. Notwithstanding the 
fact that the topic is almost worn thread- 
bare, it is one of such importance that the 
physician should be alive to the necessity 
of being ever ready to meet it, especially 
does this apply to those physicians practic- 
ing in rural districts where they do not 
have time nor opportunity to call counsel. 

"While surgery is making such rapid 
strides followed by most brilliant results ; 
he advises the younger practitioners not 
to be carried away with the idea that 
medicinal means are of no avail, in the 
tieatment of appendicitis, but urges a more 
thorough study of the disease, and accu- 
racy in diagnosis. Good sound judgment 
and anatomical knowledge of the parts 
are absolutely necessary, before the physi- 
cian can be sure of just when to call 
surgery to his aid. 

He gives a table of a series of thirty 
cases, which have occurred in his practice, 
or have come under his notice. The 
treatment was largely surgical ; a few cases 
apparently recovered under medicinal 
measures. After carefully considering the 
various means, usually employed in the 
treatment of appendicitis he summarizes as 
follows : 

1 . When called early, insist on absolute 
rest in bed. 



2. Fomentations, if pain is severe, 
and give codeine if necessary. 

3. Salines (liberal doses) every half 
hour until four to six fluid stools are pro- 
duced. 

4. If the salines, after having produced 
free catharsis, fail to relieve, or aggravate 
the pain and fever ; operate. 

5. If salines fail to produce free ca- 
tharsis; operate. 

6. Temporizing with salines, or any 
other form of medicinal treatment, is 
worse than useless. When there is the 
slightest evidence of the presence of pus, 
an operation must be done at the earliest 
possible moment. 

7. Guard against over-zealousness in 
search of the appendix, in large abscess 
cavities, lest the limiting intestinal agglu- 
tination be broken down and general peri- 
toneal infection follows. 

8. Always remove the appendix when 
it can be safely done. 

9. Elevate the pelvis, as in Trendelen- 
burg's position, in cases of small abscess 
limited to the lumen of the appendix or 
its mesenterium, or in any case when the 
peritoneal cavity is entered and where the 
intestinal distention is such as to make it 
difficult to find the caput-coli, or the ap- 
pendix. 



WHY SHOULD I NOT USE THE FORCEPS ? 



This is the title of a highly interesting ceps, mentioning the principal objections 

paper, read before the Topeka Medical to their use as well as the advantages, he 

Society, by Dr. M. R. Mitchell. concludes that three questions present 

After giving a brief history of the for- themselves, viz.: "How can they be sue- 



108 



Abstracts. 



Vol. lxviii 



cessfully and advantageously used ? " 

sl When should they be used ? " 

" Why should they be used ? " 

In answer to the first query, he says 
the main points are accurate diagnosis; 
thorough knowledge of the mechanism 
of labor; perfect cleanliness; gentleness 
and a cool steady hand. Every physician 
should possess reliable instruments and 
accustom himself to their use. 

The indication for their employment is 
a matter of judgment, and the individual 
case. 

Before resorting to the forceps the ac- 
coucheuer should have ready all necessary 
medicine^and appliances, in case of danger 



to the child, or hemorrhage following. 
Coolness and decision should characterize 
his movements under all circumstances. 
He thinks that those who condemn their 
use and portray tales of woe and bloody 
work of the instrument, have entirely 
misjudged their proper and judicious use ; 
that where properly and skillfully applied 
they do not cause laceration of the peri- 
neum that would occur in normal labor. 

He declares that many mothers' lives 
might have been saved ; and there would 
be fewer still-born children if physicians 
did not so closely adhere to that adage, 
" Meddlesome mid-wifery is always mis- 
chevious." 



A CASE OF ALBUMINURIA DURING PREGNANCY. 



In a paper read before the Obstetrical 
Society of Cincinnati, (Med. Progress), 
Dr. C. D. Palmer gave the history of a 
case of a patient who he found had consid- 
erable swelling of face and albuminous 
urine. 

Fearing puerperal convulsions, he 
placed her on saline treatment and then 
deemed it best to induce labor. 

Improvement began, and the albumen 
diminished. On fourth day after delivery, 
however, she began to have difficulty of 
breathing. On examination he found that 
she had a commencing pneumonia. She 
was placed under the influence of carbon- 
ate of ammonia and small doses of morphia. 
Next day finding an irregular dicrotic 
pulse of 140 to 150, he gave her hypoder- 



mically two drops of a one per cent, solu- 
tion of nitro-glycerine. 

Immediate improvement followed, this 
dose was repeated three times daily, for a 
while and then given by the mouth, 

The urine became less albuminous and 
breathing less laborious; at the end of a 
month the patient was discharged. 

While nitro-glycerine has no direct ac- 
tion on the heart, it has a most potent in- 
fluence, indirectly. It will increase the 
secretion of urine by directing the blood 
from the kidneys, in Brights' disease, to 
the outside of the body. 

This is the third case of this kind, in 
which Dr. Palmer has used nitro-glycer- 
ine with the same pleasing results. 



PLACENTA PRAEVIA. 



Dr. R. S. Kelso read a very interesting 
and practical paper before the South-west 
Medical Society at West Plains, Mo., 
(Kansas City, Med. , Index) on the above 
subject. He prefaces his article, by giving 
the history, symptoms and pathology of 
the trouble, and urges more thorough study 
and preparation to meet the emergency. 

The treatment varies: the general rule 
holds good, that what is best for the 
mother, is best for the child, i. e. , speedy 
delivery. 

Slight hemorrhages, require nothing 
further than close watching and rest in bed. 



When hemmorrhage is severe, or oft re- 
peated, delivery should be hastened. 

If the os is but slightly dilated, tam- 
pons may be used, — being left in for 
twenty-four to thirty-six hours. Then on 
removal if dilatation has occurred suffi- 
ciently, grasp the presenting part or turn 
and deliver. Strict antisepsis should al- 
ways be observed. 

The situation is one of such gravity that 
the physician should not loose his head. A 
steady nerve and knowledge of what to do 
at the right time, will help him in many 
trying moments. 



January 21, 1893. 



Abstracts. 



100 



Veratrune Viride in Scarlet Fever. 

In the Columbus Medical Journal Dr. 
R. E. Chambers gives his practical experi- 
ence of over thirty years, in the use of 
this remedy. He claims that it has always 
given him good results, and that when 
called to a case of scarlet fever, he has a 
remedy that will not disappoint him in 
cases free from such complications as failure 
of the kidneys to secrete, pulmonary edema, 
etc. Furthermore, these complications 
will not occur if the case is seen and treat- 
ment begun early. As proof of the use- 
fulness of the drug in this disease, he cites 
an instance in which he was called to a 
family of eight children, all ill with a 
severe type of scarlet fever, — circulation 
rapid, fever high, throats intensely swollen 
and offensive. Giving a most unfavorable 
prognosis, he began giving Norwood's 
tincture of veratrum viride with nitric 
ether; using one drop of the veratrum for 
each year of age of child, with three 
times the amount of ether. This medica- 
tion was continued every hour, until vom- 
iting was produced; then discontinued 
until fever should be manifest, then every 
three hours until vomiting should occur 
again. A solution of Chlorate of Potash 
was used in their throats, also free spong- 
ing externally. This treatment was fol- 
lowed out and in a few days the cases were 
convalescent. 

He considers the drug a safe and sure 
remedy in the treatment of scarlet fever 
even claiming that some cases be aborted 
by its timely use. 



Specific Urethritis in Children. 

Dr. John A. Weyeth, in a clinical lec- 
ture, said that gonorrhoea in young chil- 
dren is comparatively rare. Reference to 
works on diseases of children fail to show 
anything on this subject, and standard 
authorities on genito-urinary diseases men- 
tion but few isolated cases. 

He is of the opinion that there are many 
cases that escape observation, or are treated 
for something else. 

The principles of treatment do not differ 
from those which govern specific urethritis 
in an adult. The principle interest centres 
in the diagnosis, which must be accurately 
made in every suspicious case. 



Emergencies. 

Accidents in giving Anaesthetics. — 
Tincture of digitalis hypodermically ; draw 
out the tongue and see that respiration is 
not mechanically impeded; invert the 
patient quickly and temporarily; use 
forced respiration promptly ; apply exter- 
nal warmth and stimulation ; avoid the ex- 
hibition of alcohol. 

Angina Pectoris. — Inhalation of chlo 
rof orm, or a few drops of nitrate of amyl ; 
1-100 grain of nitro glycerine, internally; 
placing the feet in hot water; mustard to 
the precordial region; dry cup between 
the shoulders; hypodermic injections of 
morphine and atropine; administration of 
stimulants and anodynes. 

Apoplexy. — Elevate the head and shoul- 
ders; if pulse is moderately strong and 
the brain congested, bleed from the arm 
freely, sixteen ounces or more ; electerine 
(one- sixth grain) or croton oil, two drops 
in a drachm of sweet oil or glycerine; cold 
to the head by means of an ice bag. 

Asphyxia. — In drowning, hold the pa- 
tient's head downward for a few seconds. 
In hanging or choking, bleed from the 
jugular. If there is obstruction to passage 
of air through the mouth or nose, open 
trachea. Artificial respiration at once, 
and to be continued. Friction, warmth, 
warm bath (100°) ammonia to nostrils, 
galvanizing of phrenic nerve. 

Asthma, Spasmodic. — Hypodermic of 
atropine into the nape of the neck; inhala- 
tion of smoke of stramonium leaves ; fluid 
extract of nux vomica, internally, alcohol, 
ether, chloral, opium; inhalation of 
chloroform cautiously administered. 

Colic, Gall. — Morphine, hypodermi- 
cally; inhalation of chloroform; hot appli- 
cations to the abdomen. 

Coma. — Dark room; head high and 
cool; head shaved; low diet; croton oil; 
if due to compression, antiseptic trephin- 
ing; if due to anaemia, pilocarpine and 
hot baths. 

Heat Stroke. — Remove clothing, sprin- 
kle with water, cold cloths to the head, hot 
cloths to the feet ; antipyrin ; bleeding in 
robust subjects. After temperature is re- 
duced give alcohol and diffusible stimu- 
lants, hypodermically if necessary. 

Hiccough. — Acid drinks, cold douches, 
ether or chloroform internally, externally 
or by inhalation; musk, opium, antispas- 
modics. 



110 



Current Literature. 



Vol. Ixviii 



CURRENT LITERATURE REVIEWED. 



THE AMERICAN JOURNAL OF OBSTETRICS 

For January contains two articles on 

Ectopic Gestation. 

The paper by Dr. James W. Ross, of Toronto, 
Canada, is a scholarly article, well worth the 
attention of the practitioner, whether he be 
an abdominal surgeon or no. In his classi- 
fication of the different varieties of this acci- 
dent, Dr. Ross follows Tait and Parry closely. 
He thinks that ovarian pregnancies are as 
yet not proven and, while stranger things 
have happened, the proofs adduced do not 
seem to him convincing. Of the causes of 
extra-uterine foetation, he considers gonor- 
rhoea the most frequent; acting, as it does, 
by destroying the cilliated epithelium of the 
tube and preventing the passage of the ovum 
into the uterus. The symptoms are minutely 
discussed and stress is laid on a period of 
sterility followed by a supposed abortion. 
Should such a patient present herself with a 
pelvic mass and elevated temperature, she 
should be closely questioned as to the sup- 
posed abortion, as such, he says, are frequently 
cases of ruptured ectopic gestation. As to 
the diagnosis of extra-uterine pregnancy be- 
fore rupture, he says, " no man can be posi- 
tive of his diagnosis of intrapelvic disease 
until it is confirmed by abdominal opera- 
tion." The assertion is a sweeping one, yet 
we believe it to be true in the main. In re- 
gard to the treatment, he thinks that there 
is but one — the knife. Of electricity, he re- 
marks that there is, as the Yankee said, 
"nothing to it." The argument for and 
against electricity is discussed in the same 
masterly manner that characterizes the whole 
paper. The article closes with a table of 
extra-uterine operations. 

The second paper on 11 Extra-uterine Gesta- 
tion,"* from the pen of Dr. Edwin B. Cragin, 
of New York, deals with the subject purely 
from the operative point of view and is an 
account of the operations the author has per- 
formed, with the history of the cases. The 
article is illustrated with several photographs 
of the specimens. In his views on the diag- 
nosis and treatment, he coincides with Dr. 
Ross. 

Dr. W. W. Jaggard, Chicago, contributes a 

Note on one of the Conditions of the Use of 
Electricity in the Treatment of Uterine 
Fibroids. 

Electricity was applied in a case of multiple 
fibromata, in accordance with Apostolus 
method, with the result that the tumor be- 
came perceptibly harder and the oozing of 
blood ceased. After two or three applica- 
tions the patient developed a fatal septic peri- 
tonitis and at the post-mortem the peritoneal 
cavity contained serum, flakes of lymph, and 
two tablespoonfuls of pus. The tubes pre- 
sented signs of catarrhal salpingitis, but con- 
tained no pus. The case goes on record as a 
death following the use of electricity for 
fibroids; whether the fatal result was due to 
the agent used or not. Again, it confirms 

* " Operative Experience with Ectopic Gestation." 



the observation often made that disease of 
the adnexa is present in nine out of ten 
fibroids, as shown in those removed by 
hysterectomy. Since Apostoli has pointed 
out that tubal disease is a contra-indication 
to the use of electricity, it would seem as if 
the number of fibromata suited to his treat- 
ment is very limited. 

Ventral Hernia Following Laparotomy 

Is the title of a paper by Dr. L. H. Dunning, 
of Indianapolis. The various causes of this 
accident are well shown, such as the pro- 
longed use of the drainage tube, constipa- 
tion, and a lack of tonicity of the tissues. 
The prevention of the trouble lies in the care- 
ful approximation of the divided structures, 
with avoidance of the other conditions that 
lead to hernia. The abdominal binder is 
recommended to be worn for at least a year 
after operation. The operations for the relief 
of the hernia are clearly described. 

Dr. Samuel L. Weber, of Chicago, contri- 
butes 

A Prompt and Radical Cure of ilammary 
Abscess by a New Method of After 
Treatment. 

He treats the abscess by an incision in a line 
radiating towards the nipple and a thorough 
curetting of the abscess cavity, followed by a 
douche to wash out all debris. The cavity is 
then packed with strips of gauze soaked in a 
one per cent, carbolic solution ; the packing 
being renewed every twenty-four hours. 
After two or three days of such packing the 
cavity will be found healthy and filling up 
with granulations. The packing is now 
stopped and the wound covered with a thin 
layer of gauze over which a large flat sponge 
is placed, covered with a piece of oiled silk, 
and held in place by a firm bandage; the 
idea being to make as firm compression as 
possible. To aid in this compression, the 
sponge is soaked, after the bandage is in place, 
with the carbolic solution. The breast should 
be compressed flat against the chest and not 
in the pendant position. The author claims 
that, by this method, the duration of treat- 
ment is very much shortened. The new part 
of the treatment claimed consists in the firm 
compression. Neither principle nor method 
are new. 

Dr. J. G. Clark, of Baltimore, reports a 
"Cystoma Ovarii Glandulare Associated 
with Hydrops Polliculi. ' ' The article is illus- 
trated with three cuts of the tumor, which 
was removed at the Johns Hoskins Hospital. 

Dr. W. D. Porter contributes a paper on 
the 

Management of the Third Stage of Labor. 

His plan is a slight modification of the well 
know Crede method. As soon as the child 
is born the uterus is grasped with both hands, 
but no compression is made until one or two 
pains have occurred. With each pain com- 
pression is made, but not with enough force 
to make the woman complain. When the 
placenta is felt to have slipped into the vagina 
an antiseptic finger is passed into the vagina 
and hooked into the placenta, pulling it 



January 21, 1893. 



Current Literature. 



Ill 



gently out, while the other hand makes pres- 
sure on the uterus from above. The pro- 
cedure would seem to have no special advant- 
age over the older method. 

Dr. W. W. Jaggard reports a case of 
" Thorapagus." The monster was composed 
of two relatively equal female forms, dis- 
posed face to face, and confluent at the an- 
terior aspect of the thorax and abdomen. 
Labor lasted about eight hours, one and one- 
half hours being consumed in the extraction 
which required considerable force. Patient 
recovered. 

Dr. S. Marx, of New York, reports a " Case 
of Accidental Hemorrhage During Labor." 
Dr. Mary Almira Smith reports a successful 
case of " Porro-Cassarean Section," which 
was performed for a deformed pelvis, render- 
ing natural birth impossible. 

This number concludes with a memorial 
notice of the late Professor A. Reeves Jack- 
son. 



THE THERAPEUTIC GAZETTE. 

The two more important articles of the De- 
cember issue of the Therapeutic Gazette are 
" The Surgical Treatment of Appendicitis and 
its Limits " by Dr. W. E. Ashton and "The 
Medical Treatment of Appendicitis and its 
Limitations" by Dr. James Graham. These 
two articles were the subject for discussion at 
the Clinical Meeting of the Alumni of the 
Jefferson Medical College. Dr. Stark offers a 
paper, "The Creasote Treatment of Tubercu- 
losis. ' ' These observations are based on a per- 
sonal analysis of numerous cases. Dr. Kelly's 
" Treatment of Pneumonitis with Digitalis " 
will be read with some interest. 



THE PRACTITIONER. 

TJte Practitioner comes to us for December 
with three articles. The most important of 
these is " The Dietetic and Medicinal Treat- 
ment of Rheumatoid Arthritis " by Dr. John 
K. Spender. 



THE GLASGOW MEDICAL JOURNAL. 

Dr. Buchanan's paper, 

A Case of Puerperal Fever, illustrating the 
node of Infection and the Infective Agent, 

says, in discussing the source of the in- 
fective agent, that there is a deep-rooted 
belief that this is conveyed in most cases 
to the patient; and no doubt it is very 
often transmitted from other cases of puer- 
peral fever, but it is probable that in a 
considerable number of cases the patient her- 
self is the source of the infection. For the 
streptococcus pyogenes, which is always pres- 
ent in these cases, may be cultivated from 
mucuous surfaces apparently healthy. He, 
therefore, believes that this microbe is pres- 
ent in the vagina before labor . It may be in- 
troduced into the uterus before or after labor. 
Moreover, he further states, there is a possi- 
bility of infection from an " old unilateral sal- 
pingitis. ' ' Mr. John McGregor's article ' ' The 
Epidemic of Cholera in Paris " and three 



small papers read before the Glasgow Patho- 
logical Society complete the December issue. 



EDINBURGH MEDICAL JOURNAL. 

In December's number Mr. Milton offers a 
" few words " about the pathology and treat- 
ment of "Lupus" — before the tale is told 
quite a lengthy article appears. Dr. A. G. 
Miller's paper, 

Excision or Arthrectomy of the Knee Joint, 

states that by the terms excision and arthrec- 
tomy is meant that operation, exclusive of 
amputation, by which all the diseased tissues 
are removed, with the best possible results 
to the patient in the shape of a useful 
limb. He says that experience has taught 
him that, to get a satisfactory result in stru- 
mous joints, it is necessary to remove the 
whole of the diseased synovial membrane. 
His method in operating is, after reflecting a 
semilunar flap of skin well above the patella, 
to cut through the tendon of the extensor of 
the thigh a little above the patella, and also 
through the fibres of the vasti, internal and 
external. In this way the synovial mem- 
brane is exposed. It is then easy to push up 
the muscular substance, draw down the 
thickened synovial membrane, which comes 
off the periosteum readily, and then to cut at 
its attachment round the articular surface of 
the femur. In this way four-fifths, or there- 
abouts, of the synovial membrane is removed 
in one mass with the patella imbedded in it. 
Those portions of the membrane that cover 
the ligaments are then removed by the use of 
the Lister sharp spoon. - The ligaments should 
be scraped till they appear clean and white. 
They are then cut through to permit of com- 
plete flexion of the joint, and the operation is 
completed by the removal of a sufficient 
amount of bone. There seems to be one fact 
further to consider in the review of this 
paper, and that is, the removal of the patella, 
which, he states, is not an object of his oper- 
ation, but is a necessary part, for it comes 
away in the centre of the synovial mass. He 
does not consider the removal of the patella a 
disadvantage; because (1), it is often di- 
seased ; and, (2), if the resulting limb be 
thoroughly anchylosed and rigid the function 
of the patella is gone, and the straight limb 
looks neater without it. 

" Some Practical Results of the Investiga- 
tion of Cholera in Germany," by Dr William 
Russell completes the list of communications 
of any merit. 



THE DUBLIN JOURNAL OF MEDICAL SCIENCE. 

Of the five papers offered in the December 
number possibly the most important one is 
an address by Dr Hamilton, President of the 
Section on Surgery in the Royal Academy ot 
Medicine in Ireland, on "The Surgery ot 
To-day." He gives an exceedingly inter- 
esting and instructive account of the growth 
of surgery from the time when bleeders, 
cuppers, and leechers were in vogue to the 
placing of surgery on a tripod of three solid 
and enduring feet— anaesthetics, antiseptics 
and experimental research. 



112 



Selected Formulce. 



Vol. lxviii 



SELECTED FORMULAE. 



Emulsion Castor Oil. 

TV Castor oil i oz. 

XV Syrup rhubarb 4 drachms. 

Alcohol 4 drachms. 

Essence peppermint 2 drops. 

Mix, and shake well together. The taste of the oil is 
completely disguised. 

— Phar. Era. 



Liniment for Neuralgia. 

13 Chloroform 5vi. 

XV Sulphuric ether Si. 

Spirits camphor Siii. 

Tinct. opium 3iss. 

M. Sig.— Soak a small piece of flannel with the lini- 
ment, and apply over the painful part. 

—The Doctor. 



To Clean Cistern Water. 

Add two ounces of powdered alum and two ounces of 
borax to a twenty-barrel cistern of rain water that is 
blackened or oily, and in a few hours the sediment will 
settle, and the water will be clarified and fit for washing. 

— Tex. Health Jour. 



Serous Diarrhoea. 

Pulv. opii , gr. i. 

Plumbi acetat gr. ii. 

Camphorae gr. i. 

ft. Pil. no. 1. 

—II. A. Hare. 



For Removing Warts. 

A most successful means of removing the 
ordinary wart, whether situated on the 
hands or elsewhere, is as follows: 

O. Add salicylici g. xxx. 

XV Ungt. aquae rosae I ss. 

M. S. Apply twice daily for two days, after which the 
growths being softened, they should be removed by a 
dermal curette, and by using these means you can safely 
say that the wart will not return. 

— J. Abbott Cantrell. 



For Frost Bite. 

"D Ol. lavandulae 

XV Acid, carbolic aa fSss. 

Olei oliv f5y. 

Unguent, plumbi 

Lanoliui aa 5x. M- 

Ft. ung. Sig.— Apply topically. 

— Lassar, Med. News* 



Habitual Constipation. 

TV Extract physostigmatis 
XV Extract belladonnas 

Extract nucis vomical aa gr. 

Aloin gr. 

M. ft. Pil. 

—Prof. R. Bartholoiv. 



Coccydynia. 

Whitla recommends the following supposi- 
tory employed at bed-time. 

T> Ext. belladonnas giain. 

Ext. hyoscyami % grain. 

Iodoform % grain. 

Ol. theobromae 20 grains. 

Nervous Cough. 

T> Acidi Hydrocyanic Dil 1 drachm. 

XV Tinct. Sanguinariae y 2 ounce. 

Syr. Senegae 4 drachms. 

Aquae I,auro-cerasi 7 drachms. 

Spr. Tolu 2 ounces. 

M. Sig. From ten drops to a teaspoonful every four 
hour*, according to the age of the patient. 

—The Doctor. 



Painless Dilatation of the Cervix Uteri. 

For this purpose, Le Fort recommends: 

T> Iodoform 3 Hi. 

XV Powdered cocaine gr Ixxx. 

Sulphuric ether Siii. 

Make a solution, and wet a laminaria tent with the 
same. This may then be introduced into the uterine 
canal, and dilatation obtained without causing pain. 

— L J Union Med. 



For Small Hemorrhoids and Pruritus Ani. 

T). Hydrarg. chlo. mitis gr. xx. 

XX Cocaine muriat gr. x. 

Petrolati gi 

M. ft. ung. 

Sig. Apply as directed. 



An Ointment for Hemorrhoids. 

T>. Hydrochlorate of cocaine gr. xviii. 

XV Sulphate of morphine gr. iv. 

Sulphate of atrophine gr. iv. 

Tannic acid gr. xviii. 

Vaseline Ii. 

This ointment is to be applied to the hemorrhoids. 

— L J Union Med. 



Tape Worm. 

Treatment.— Fast patient eighteen hours, and purge 
during the time. Then give, hourly, wineglass doses of 
pomegranate decoction, made as follows: 

T>. Fresh Pomegranate Bark 2 ounces. 

XV Aquae Purae , 2 pints. 

Boil down to one pint, strain and use. 

It is necessary to get the head in order to establish a 
permanent cure. 

—The Doctor. 



Detection^ of Pus in the Urine. 

Drop into the specimen of urine enough tincture of 
guaiac to give it a milky appearance, and heat it a few 
minutes to ioo°F. If pus is present a blue tint will 
develop. Otherwise, the urine may be passed through a 
white filter, on which is then allowed to fall a few drops 
of tincture of guaiac, producing, if pus is present, a dis- 
tinct blue discoloration. 

— Ex. 



Treatment of Gonorrhoea. 

Dr. W. J. James, of Cleveland, Ohio, has 
employed the following injection with excel- 
lent results in the treatment of a case of 
chronic gonorrhoea, where solutions of sul- 
phate of zinc, nitrate of silver and bichloride 
of mercury proved inefficient, and he has de- 
rived equal benefit from it in acute cases. 

T>. Boracic acid 5iss. 

XV Tincture of iodine 5ii. 

Glycerine Si. 

Distilled water q. s. ad Siv. 

M. Sig. To be used as an injection every morning and 
night. 

He would like other physicians to give this 
formula a trial. — Med Bull. 



January 21, 1893. Selected Formttlce. 



Solution for the Treatment of Chancre. 

Du Castel is stated to use the following 
solution in the treatment of chancre, by 
V Union Medieale. 

TV Carbolic acid. gr. xv. 

XV Alcohol (90 per cent.) Siiss. 

Make a solution, and with a small pledget of cotton or 
wool touch the surface of the chancre. A light touch is 
generally sufficient. Cicatrization usually readily en- 
sues. 

—Ther. Gaz. 



Catarrh, Acute Nasal, with profuse watery 
Secretion. 

TV Tinct. Aconiti Radicis 

XV Tinct. Belladonae aa Sij. 

Tinct. Apii deodoratae S iv. 

M. Sig.— 10 to 12 drops in water every three or four 
hours. 

— W. H. Bricker. 



Fifth.— It should be administered in com- 
bination with approved adjuvant remedies. 

There are several easy and palatable 
methods of administration. The following 
prescriptions are ordinarily employed by me, 
the daily doses being dissolved in some 
alcoholic or vinous mixture, as whiskey or 
sherry wine. 

TV Creosoti (beech wood) mxlv. 

XV Glycerini Si. 

Aquae destil ad Sii. 

Dose.— Si t. i. d. 

TV Creosoti (beechwood) Si. 

XV Tinct. gentian comp Sii. 

Dose.— mxv t. i. d. 

TV Creosoti (beechwood) Sss; 

XV Bismuthi subnitrat Si. 

M. et f. in capsul. no. xv. 
Dose.— One every four hours. 



For Asthma. 

Bartholow recommends: — 

TV Potassii iodide 3 iij. 

Xjtf Ext. belladonnae fluid fSj. 

Ext. lobeliae fluid f S ij. 

Ext. grindeliae fluid f 5 ss. 

Glycerini f S iij. 

Sig. — A teaspoonful as required. 



Transfusion Fluids. 

The following are given in the Prescription: 

1. Billroth's. 

TV Sodium phosphate gr.iij. 

XV Sodium carbonate 

Ammonium carbonate aa 9>j. 

Sodium chloride .. 5j. 

Alcohol mclx. 

Dist. water q. s. ad Sxx. 

M. 

2. Little's. 

TV Sodium phosphate gr-iij. 

XV Potassium chloride gr. vj. 

Sodium carbonate 9ij. 

Sodium chloride 5j. 

Dist. water q. s. ad Sxx. 

M. 

3 Walter's. 

TV Sodium bicarbonate 
XV Calcium chloride 

Potassium chloride aa gr. vj. 

Sodium chloride Sj. 

Distilled water q. s. ad Sviij. 

M. 

For use, dilute i fl. oz. of this solution with water at 
i2o°F., so as to make 16 fld. oz. 



Dr. Stark, Therapeutic Gazette, in conclud- 
ing his paper on " The Creasote Treatment of 
Tuberculosis," submits the following resume: 

First. — Creasote is no longer an innovation 
or a fad, but a drug which has come to stay 
as an antitubercular remedy. 

Seconal. — Creasote is particularly valuable 
in the earlier stages of tuberculosis. 

Third.— Its administration must be in 
moderate doses for a prolonged period. 

Fourth.— That it is a safe and reliable pro- 
phylactic in the condition that is usually 
described as pretubercular anaemia. 



" Which side should I sleep on, doctor?" 
he inquired. " In winter or summer?" 
asked the doctor, rubbing his chin 
thoughtfully. " What's that got to do 
with it?" exclaimed the patient, half an- 
grily. " A great deal," responded the 
doctor, mysteriously. "I don't see it." 
" Of course you don't," said the impertur- 
bable; " if you did you wouldn't be here 
asking me questions about it." " Go 
ahead, then," said the patient, sitting 
back resignedly. " Well," continued the 
doctor, "in winter, when it is cold, you 
should sleep on the inside; but in such 
weather as this you should sleep on the 
outside, in a hammock with a draught all 
round it, and a piece of ice for a pillow. 
Two dollars, please." — Med. Record. 

Man, bom of woman, is of few days and 
no teeth. And indeed it would be money 
in his pocket sometimes if he had less of 
either. As for his days, he wasteth one- 
third of them. And as for his teeth, he 
has convulsions when he cuts them. And 
as the last one comes through, lo! the 
dentist is twirling the first one out ; and 
the last end of that man's jaw is worse 
than the first, being full of porcelain and 
a roof-plate built to hold blackberry seeds. 
— Burdette. 

Polite Doctor (cautiously) — " Your 
husband is suffering from overwork or ex- 
cessive indulgence in alcoholic stimulants 
— it is, ahem! a little difficult to tell 
which." 

Anxious wife — "Oh, its overwork! 
Why, he can't even go to the theatre with- 
out rushing out half a dozen times to see 
his business partners." — Judge. 



114 



Periscope. 
PERISCOPE. 



Vol. lxviii 



MEDICINE 

Tendon Reflexes. 

The following classification of tendon re- 
flexes by Dr. William C. Krauss (Buffalo 
Med. and Surg. Jour.) will be found useful: 



! 
1 




i. 


Myelitis 








2 - 


Amyotrophic lateral scle- 










rosis. 








3- 


Paraplegia spastica. 








4- 


Multiple sclerosis. 








5- 


Syringomyelia and hy- 










dromyelia. 








6. 


Hematomyelia and he- 


Exag- 




Spinal 




matorrhacis. 


gera- 




Cord. 


7- 


Spinal tumors. 


tion of 






8. 


Pachymeningitis hemor- 


Ten- 








rhagica interna. 


don Re- 






9- 


Pachymeningitis cervi- 


flexes. 


Organ- 






caiis hypertrophica. 






IO. 


Brown- Sequard's spinal 




ic Dis- 






paralysis. 




ease. 




ii. 


Arthritic muscular atro- 










phies. 










f Cerebral 










1 apoplexy. 










| Cerebral 








I 


Hemiplegia. \ embolism 










| thrombo- 






Brain. 




I sis. 










j Acute en- 










cephalitis 








2. 


Hematoma. 








3- 


Hydrocephalus 








4- 


Senile dementia. 








i. 


Hysteria. 








2. 


Epilepsy. 




Func- 




3- 


Neurasthenia. 




tional 




4- 


Paramyoclonus. 




Dis- 




5- 


Tetanus. 




ease. 




6. 


Psychoses. 








7- 


Infectious processes. 



Abolition of Ten- 
don Reflexes. 


1. Neuritis. 

2. Locomotor ataxia. 

3. Poliomyelitis an- 
terior. 

4. Spinal muscular 
atrophies. 

5. Hereditary ataxia 
(Friedreich.) 

6. Chorea molle. 

7. Chronic ergotism. 

8. Diabetes mellitus. 

9. Traumatism. 


Simple. 
Toxic. 
Endemic. 
Infective. 


Abolition and Ex- 
aggeration. 


1. Meningitis. 

2. Hementia paraly- 
tica. 

3. Idiocy. 


Spinal. 
Cerebral. 



Congenital Syphilis. 

Erlenmeyer (Zeitschrift f. Min. Medicin, 
xxi, 3 u. 4, p. 343) has reported seven inter- 
esting cases of congenital syphilis which he 
has studied in their relations to certain dis- 
eases of the nervous system. He expresses 
the view that late forms of congenital sy- 
philis, so-called syphilis hereditaria tardia, 
may appear later than the twelfth year — that 
is hereditary syphilis may remain latent 
more than twelve years. Puberty, trauma- 
tism, and febrile affections may afford the 
necessary stimulation to arouse into activity 
a latent congenital syphilis. The law of 
Colles, that the mothers of children congen- 
ially syphilitic through the fathers, is not 
without its limitations. Mothers that have 
given birth to congenitally syphilitic chil- 
dren may become syphilitic, though not 
necessarily. Immunity to syphilis is not 
identical with infection with syphilis. The 
law of Kassowitz as to the spontaneous grad- 
ual attenuation of the intensity of the syphi- 
litic hereditary transmission is not absolute. 
Children born late may be infected in more 
intense degree than those born previously. 
Hereditary syphilis may alternate with the 
sexes ; thus, if after the birth of a congeni- 
tally syphilitic child a non-syphilitic child of 
different sex is born, it is not proved that the 
capability of hereditary transmission through 
the father is exhausted. In arriving at a 
conclusion all the children must be considered. 
Anti-syphilitic treatment of the parents ex- 
erts a most favorable influence upon subse- 
quent children. A form of cerebral disease 
development characterized by unilateral con- 
vulsions and lack of development is most 
commonly of syphilitic origin. The so-called 
cerebral paralysis of children and congenital 
epilepsy, with or without idiocy, are fre- 
quently dependent upon congenital syphilis. 
— Med. JVeivs. 



Right Hemiplegia and Aphasia Following 
Diphtheria in a Child. 

Allen A. Jones, M. D., Lecturer on Practice 
of Medicine and Instructor in Practice, Medi- 
cal Department University of Buffalo, con- 
tributes the following to the Medical News: 

In May, 1891, I attended Florence T., eight 
years old, during a severe attack of diph- 
theria. The local and constitutional mani- 
festations of the disease were pronounced, but 
the patient passed safely through the severe 
stages, and in about ten days was free from 
pyrexia, had a clean throat and a good pulse. 
The child seemed so well that I ceased making 
daily visits. One morning however, I was 
hurriedly called, and found her with com- 
plete right-sided hemiplegia and ataxic aph- 
asia. The right side of her face was entirely 
paralyzed. Her mother informed me that 
the child was talking and laughing an hour 
before I was summoned. 



January 7, 1893. 



Periscope. 



115 



She was not unconscious at any time. The 
usual evidences of pharyngeal paralysis ex- 
isted. No cardiac bruit was detected. The 
patient's mentality seemed sluggish for a few 
hours subsequently to the attack, but there- 
after was normal. 

Her repeated attempts to make herself 
understood were unavailing, as she produced 
only inarticulate sounds. Sensation was nor- 
mal, so far as I was able to elicit. The 
patellar reflex was very weak and alike on 
both sides. Headache was not present. No 
pain was felt in any part of the body. After 
the lapse of two days, she was able to extend, 
but not to flex, her leg. Motor power gradu- 
ally returned, first in the leg and thigh, then 
in the hand and arm, lastly in the face and 
pharynx. In about six weeks the little 
patient was playing out-of-doors, apparently 
as well as before her illness. 

A few days ago I went to see her, and was 
struck by her frail appearance. She has 
grown very little, if any. She is very thin. 
Her eyes are large and her pupils dilated. 
No areas of anesthesia were found. Her 
patellar reflexes on both sides were almost 
imperceptible. Her sister states that the 
child has always spoken slowly since her 
illness. Her grandfather states that she has 
never been the same since, but is weak in 
body and mind. 



Jaborandi in Hiccough. 

Nobel and Stiller {Centralbl. f. Klin. Med., 
1892, Nos. 32 and 42) respectfully refer to the 
good effects produced by jaborandi in hic- 
cough. Nobel's patient was a man suffering 
from influenza, and the infusion of jaborandi 
was used. Nobel draws attention to the fact 
that, notwithstanding the presence of some 
cyanosis, the drug had no ill effect upon the 
heart. He refers to other recorded cases, and 
adds that it remains to be proved which con- 
stituent in jaborandi brings about the good 
results. Stiller says that he has long used 
pilocarpine (10 drops of a 1-per-cent. solution 
three or four times a day) in hiccough of 
nervous origin, and that it is the best remedy 
known for this condition. He does not 
employ it in the reflex hiccough of severe ab- 
dominal disease and peritonitis. At times, 
and especially in hysteria, only improvement 
or temporary cessation in the hiccough has 
been obtained, necessitating the further use 
of the drug. Stiller says that the good effects 
of jaborandi are due to pilocarpine. — Med. 
Age. 



Gout in a Child Eleven Years Old. 

Marboux {Lyon Medical, 1892, No. 43, p. 
264) has reported the case of a girl, eleven 
years old, in which, after a brief period of 
malaise, sore-throat, and difficulty in swal- 
lowing, pain, redness and swelling appeared 
at the metatarso-phalangeal joint of the right 
great toe. On the following day, the symp- 
toms subsided with the abruptness with 
which they had appeared, some discoloration, 



pain, and swelling, however, persisting. A 
day later, the great toe of the left foot became 
similarly involved. Forty-five grains of 
sodium salicylate were administered in 
twenty-four hours, and decided improvement 
followed. There was no doubt from the mode 
of onset, from the appearance of the affected 
parts, and from the progress of the case, 
that the condition was gout. There was no 
family history of gout on either the father's 
or on the mother's side. The father had, how- 
ever, eighteen months previously, had an at- 
tack of the same kind as the child. The 
child did not suffer from migraine or from 
gastric disorder or from cutaneous eruptions, 
nor had menstruation occurred. — Med. Neivs. 



Expectant Treatment in Typhoid Fever. 

Dr. Arnot Spence details the results from 
this plan in three hundred and twenty-three 
cases of typhoid fever {Med. Bee). Upon 
terminating his article he says: In conclusion 
we can say that of our cases nearly four per 
cent, died as the result of admission in a mor- 
ibund state ; that over three per cent, died of 
the accidents incidental to the intestinal 
lesions, as hemorrhages, perforation, and 
peritonitis ; that 1.5 per cent, died of com- 
plicating pneumonia ; that 6.8 per cent, died 
of the typhoid poison itself and its resulting 
exhaustion. That the death-rate was higher 
among the females than the males, and that 
the lowest mortality was in those cases of an 
age between fifteen and twenty years. 

It is not likely that any treatment can be 
devised which will prevent absolutely such 
occurrences as intestinal hemorrhages and 
intestinal perforations, and therefore we shall 
have those to contend against. A treatment 
which may possibly antidote the specific 
poison of typhoid fever without lowering the 
vitality of the patient will be, in accordance 
with our present theory, the one to reduce its 
mortality.— Wkly. Med. Rev. 



Treatment of florphinism. 

Obersteiner individualizes strictly in the 
treatment of the morphine habit. Beginning 
with the average daily dose, he withdraws it 
as rapidly as the patient can stand it. When 
the dose has been reduced to a few centi- 
grammes, caution is necessary, as even a 
slight reduction is then badly borne. At this 
stage warm baths of from 5 to 15 minutes' 
duration, followed if necessary by the cold 
shower or cold pack for one-half hour to two 
hours at a temperature of 78° to 86° F., are 
often of benefit. Alcohol in liberal quantities 
often gives relief. Cocaine has no other use 
than to modify the symptoms, and should 
only be used when these become violent, say 
twenty-four to forty-eight hours after the last 
dose of morphine; it is always given by 
mouth in doses of 0.05 to 0.1 gramme, never 
exceeding 0.5 gramme per day, it should be 
reduced in a few days, and never continued 
longer than five or six days. Nutrition must 



116 



Periscope. 



Vol. lxviii 



be improved by all possible means. If col- 
lapse occurs, morphine must be resorted to. 
Patients with cardiac troubles should not be 
subjected to complete withdrawal. — Wien. 
Med. Presse. 



SURGERY. 

Radical Cure of Femoral Hernia. 

Salzer describes a new method of radical 
cure of a large femoral hernise. He objects to 
any attempt to bring together the margins of 
the ring by sutures, as the resistance of the 
fibrous structures would very probably cause 
local gangrene and sloughing. The plan of 
closing the canal by cicatrical tissue, either 
by removing its fatty and glandular contents, 
or by inserting foreign material, is also open 
to objection, as the new tissue thus produced 
is apt to become absorbed. His method con- 
sists in first removing the sac, and in the next 
place, in closing the external orifice by a flap 
formed by the fascia covering the pectineus 
muscle. This flap, the free convex margin of 
which is divided downwards, whilst its upper 
portion remains attached to the muscle, is 
turned upwards and fixed by sutures to the 
middle third of Poupart's ligament. In this 
way the septum crurale is replaced by a tough 
and resistant layer of fibrous tissue. The 
thickness of the pectineal fascia, it is stated, 
varies in different subjects, but the membrane 
is most likely to be found sufficiently re- 
sistent in old persons, and in those who have 
for a long time worn a truss for femoral 
hernia. — Brit. Med. Jour. 



Significance of the Subjective Cerebral 
Symptoms in Middle=Ear lnflam= 
mation. 

Dr. H. Knapp (Archives of Otology) says : 

1. Transient headache, nausea, vomiting, 
and dizziness, in acute cases, indicate menin- 
gitic irritation. These cases almost all re- 
cover with or without mastotomy, only a few 
exceptional cases of fatal termination being 
on record. 

2. Persistent headache, nausea, vomiting, 
and dizziness especially when the discharge 
from the ear diminishes, signify transition of 
meningitic irritation into real meningitis, and 
demand surgical interference — paracentesis of 
the drum membrane, especially the membrana 
flaccida when bulging, or opening of the 
mastoid after Schwartze or Kuster. 

3. The above symptoms with delirium, 
stupor, impediment of speech, chills, spasms, 
drowsiness, and coma signify fully developed 
intracranial suppuration. In the majority of 
such cases it may be difficult or impossible to 
discriminate between thrombo-phlebitis, ex- 
tradural and cerebral or cerebellar abscess. 
The special diagnosis and localization, when 
strengthened by valuable objective symp- 
toms, such as painful swelling and hardness 



of the internal jugular vein (sinus throm- 
bosis), localized pain spontaneous or on per- 
cussion of the skull (abscess), a fistula in the 
cranial bones (extradural suppuration), may 
justify, even demand, surgical interference, 
namely, opening the posterior cranial fossa 
to ligate and cleanse the lateral sinus, or 
opening the posterior or middle fossa to 
liberate the extradural accumulation of pus, 
or opening the middle or posterior fossa to 
evacuate an encephalic abscess. Of all these 
varieties a certain, though small number of 
cases (seventeen) is known in which the 
diagnosis was correctly made and the opera- 
tion successfully performed. — Am. Ban. 



Clinical Classification of Hip= Disease. 

In a consideration of coxitis Dr. Robert W. 
Lovett divides the trouble clinically (Boston 
Med. and Surg. Jour.) into four types. These 
four types are: 

1. The Destructive Form, where the dis- 
ease is rapid, severe, but little influenced by 
ordinary treatment; extensive infiltration of 
the soft parts takes place, and in most in- 
stances the disease passes on to a fatal issue. 

2. The Painful Form, where pain is a prom- 
inent symptom, and exacerbations are com- 
mon. 

3. The Quiet or Painless Form, where pain 
is an unimportant factor or is entirely absent. 

4. The Transient or Ephemeral Form, 
where the symptoms are mild and the course 
of the disease is run in a few months. 

1. The Destructive Form— The type of hip- 
disease which he would place in this class 
occurs most often in children of tuberculous 
inheritance and poor vitality. Its onset is 
rapid and painful, often excessively painful. 
There is, almost from the first, much thick- 
ening of the trochanter and peri-articular 
tissues. The general condition is rapily im- 
paired, and abscess formation takes place 
early. One abscess follows another with pro- 
fuse discharge through sinuses which open 
widely and are surrounded by colorless gran- 
ulations. This type of disease most often 
begins as such, and is clearly a type by it- 
self throughout. At other times, but rarely, 
it is superadded to one of the forms about to 
be described. The temperature is high, the 
wasting rapid, and a porky induration of the 
thigh ensues. — Med. Rev. 



Treatment of Appendicitis. 

1. All cases of catarrhal and ulcerative ap- 
pendicitis should be treated by laparotomy 
and excision of the appendix as soon as the 
lesion can be recognized. 

2. Excisions of the appendix in cases of 
simple, uncomplicated appendicitis is one of 
the easiest and safest of all intra-abdominal 
operation. 

3. Excisions of the appendix in cases of 
appendicitis before perforation has occurred, is 
both a curative and prophylactic measure. 



January 21, 1893. News and 

4. The most constant and reliable symp- 
toms indicating the existence of appendicitis 
are recurring pains and circumscribed tender- 
ness in the region of the appendix. 

5. All operations should be done through 
a straight incision; parallel to and directly 
over the caecum. 

6. The stump after excision of the appen- 
dix should be carefully disinfected, iodo- 
formized and covered with peritoneum by 
suturing the serous surface of the caecum on 
each side over it with a number of Lambert 
stitches. 

7. The abdominal incision should be closed 
by two rows of sutures, the first embracing 
the peritoneum, and the second the remaining 
structures of the margins of the wound. 

8. Drainage in such cases is unnecessary 
and should be dispensed with.— Med. Prog. 



NEWS AND MISCELLANY. 



Salipyrin, the sale of which has been inter- 
dicted in the United States during the past 
year, because of conflicting proprietary in- 
terests, is now free for use in this country. 
(December, 1891,) Notes on New Remedies 
published a complete descriptive article on 
salipyrin. The product has been adopted in 
medical practice in Europe, and many clin- 
ical reports have resulted from trustworthy 
and authoritative sources. It is expected 
that physicians in this country will take up 
the remedy, and that the favorable results ob- 
tained by European physicians will be re- 
peated here. 



Dr. Mary Putnam Jacobi has been elected 
as president of the Neurological Section of 
the New York Academy of Medicine, at its 
last meeting to succeed Dr. Greame M. Ham- 
mond. 

Mrs. Jacobi is the first female physician 
ever elected to the distinguished position of 
the presidency of a section, in the New York 
Academy since its foundation; now more 
than twenty-six years. 

This is an honor deservedly bestowed on 
one who richly merits this unique and dis- 
tinguished promotion ; for though Mrs. Dr. 
Jacobi is no nerve specialist, her knowledge 
of diseases of the nervous system is deep and 
thorough. 

It may be said, of this distinguished medi- 
cal matron, that while progressive and ag- 
gressive as a writer, teacher and practitioner 
of the healing art, she yet preserves to a high 
degree, those feminine charms and graces so 
peculiar to the refined and cultured lady. 



Dr. Thomas Lyon, the oldest and one of 
the most prominent physicians in Williams- 
port, died at his residence, December 25, 1892. 
His illness was of brief duration, only since 



Miscellany. 117 

the 24th of last month, up to which time he 
gave earnest attention to his practice as a 
physician, although he was in the eightieth 
year of his age. 

He was the father of six children, of whom 
four are living. 

The following biography of the venerable 
physician appears in Meginness' Historical 
Journal issued in 1888: 

" Dr. Thomas Lyon now takes rank as the 
oldest physician in active practice in Williams- 
port, Pa. He is a son of Edward Grundy Lyon 
and Sarah Lyon, of English birth, and was 
born October 13, 1812, near the borough of 
Muncy, Lycoming County, Pa. He received 
his education at the celebrated Milton acad- 
emy, when the distinguished Rev. Dr. 
Kirkpatrick was the principal. He studied 
medicine under the famous Dr. James S. 
Dougal, of Milton, and graduated at the Jef- 
ferson Medical College, Philadelphia, 1838. 
When he located in Williamsport it had less 
than one thousand inhabitants, and he has 
followed his profession without interruption 
down to the present day. Dr. Lyon has 
made surgery a specialty, though his practice 
is general. He is a member of the Williams- 
port Medical Society, of the Lycoming 
County Medical Society, of the Pennsylvania 
State Medical Society and the American 
Medical Association. He has been president 
of the city and county associations and vice- 
president of the State Medical Society. Dur- 
ing the war he was a member of the medical 
board of examiners for army surgeons. His 
contributions to medical literature have been 
published in the transactions of the State 
Medical Society. In 1843 he married Eliza- 
beth R., daughter of Joseph R. Priestly, 
Esq., of Northumberland, and great-grand- 
daughter of Dr. Joseph Priestly, the eminent 
chemist and discoverer of oxygen. Dr. 
Lyon, although in the fiftieth year of active 
practice, is still hale and vigorous, and gives 
promise of many more years of service." 



ARMY AND NAVY. 



FROM JANUARY 8, 1893, TO JANUARY 14, 
1893. 

The leave of absence granted First Lieuten- 
ant Samuel R. Dunlop, Assistant Surgeon, 
U. S. Army, is still further extended to in- 
clude January 31, 1893. 

The resignation of First Lieutenant Samuel 
R. Dunlop, Assistant Surgeon, U. S. Army, 
has been accepted by the President to take 
effect January 31, 1893. 

The order directing Major Robert M. 
O'Reilly, Surgeon, U. S. Army, to proceed to 
Washington, D. C., and report for duty as 
Attending Surgeon, is suspended until further 
orders. 

Lieutenant Col. Charles R. Greenleaf, 
. Deputy Surgeon General, U. S. Army, is de- 



118 



News and Miscellany. 



Vol. lxviii 



tailed as a delegate to the Eleventh Inter- 
national Medical Congress to convene at 
Home, Italy, on the 24th of September, 1893, 
and will, at the proper time, proceed to the 
place designated. While abroad in pursu- 
ance of this order, he will visit such points in 
Great Britain, France, Germany, Russia, 
Austria, Italy, and elsewhere as may be 
deemed necessary by the Surgeon General of 
the Army, on official business, and on com- 
pletion of the duty contemplated will return 
to his station in this city. 

First Lieutenant J. D. Glennan, Assistant 
Surgeon, U. S. Army, having reported at 
Head-quarters Department of Texas, will pro- 
ceed to Carrizo, Texas, and report to the com- 
manding officer of the Seventh Cavalry sqad- 
ron at that place for duty. 

Leave of absence for one month, with per- 
mission to apply for an extension of one 
month, is hereby granted Captain J. S. 
Powell, Assistant Surgeon, IT. S. Army. 

First Lieutenant B. S. Ten Eyck, Assistant 
Surgeon, U. S. Army, having reported for 
duty at Head-quarters Department of Texas, 
will proceed to Laredo, Texas, for service in 
the field, to relieve Captain W. B. Davis, As- 
sistant Surgeon, who, upon being thus re- 
lieved, will return to his station, Fort Sain, 
Houston, Texas. 

First Lieutenant Frank R. Keefer, Assist- 
ant Surgeon, U. S. Army, is relieved from 
duty at Fort Riley, Kansas, and will report 
in person to the commanding officer, Fort 
Stanton, New Mexico, for duty at that post, 
relieving Captain John M. Banister, Assist- 
ant Surgeon. 

Captain Banister, upon being relieved by 
First Lieutenant Keefer, will report in per- 
son to the commanding officer, Fort Leaven- 
worth, Kansas, for duty at that post. 



U. S. MARINE HOSPITAL SERVICE FOR THE 
FOUR WEEKS ENDING JANUARY 7, 1893. 

Purviance, George, Surgeon, detailed as 
chairman of board for physical examination 
of Passed Assistant Surgeon, S. C. Devan, 
Dec. 21, 1892. 

Gassaway, J. M. Surgeon, to proceed to 
Gulf Quarantine on special duty, Jan. 4, 
1893. 

Devan, S. C, Passed Assistant Surgeon, to 
report for physical examination, Dec. 21, 
1892. Detailed for special duty at Philadel- 
phia, Pa., Dec. 28, 1892. Granted leave of 
absence for two months on surgeon's certifi- 
cate of disability, Jan. 7, 1893. 

Kallock, P. C, Passed Assistant Surgeon, 
to assume command of the service at Cincin- 
nati, Ohio, when relieved at Boston, Mass., 
Dec. 21, 1893. 

Glennan, A. H., Passed Assistant Surgeon, 
leave of absence extended sixteen days on ac- 
count of sickness, Dec. 13, 1892. To proceed 
to New York, N. Y., for special temporarv 
duty, Jan. 3. 1893. 

Williams, L. L., Passed Assistant Surgeon, 
to proceed to Helena, Arkansas, on special 
duty, Jan. 3 1893. 

Mcintosh, W. P., Passed Assistant Sur- 
geon. When relieved to proceed to Boston, 
Mass., for duty, Dec. 21, 1892. 

Magruder, G. M., Passed Assistant Sur- 
geon. When relieved to proceed to San 
Diego, Cal., on special duty, thence to New 
Orleans, La., for duty, Dec. 16, 1892. 

Cobb, J. O., Passed Assistant Surgeon. 
When expiration of leave of absence to pro- 
ceed to Port Townsend, Wash., for duty, 
Dec. 21, 1892. 

Stimpson, W. G., Assistant Surgeon, to 
proceed to Detroit, Mich., for duty, Dec. 20, 
1892. 



JANUARY 28, 1893 



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ORIGINAL ARTICLES. 

E. H. Townsend, M. D., New Lisbon, Wis. 



Locomotor Ataxia 



CLINICAL LECTURES. 

John B. Hamilton, M. D„ LL. D., Chicago. 
Tuberculosis of the Shoulder Joint; Tonsillotomy; 
Tuberculosis of the Hip Joint 122 

COMMUNICATIONS. 

Jas. S. Chenoweth, M. D., Louisville, Ky. 

Technique of Supra-Pubic Cystotomy . . . i26 
John C. Holmes, Cranbury, N. J. 

Nursing in Typhoid Fever 128 

W. C. Dugan, M. D., Louisville, Ky. 

A Case of Cerebral Surgery ...... 130 

A. O. Stimpson, M. D., C. M., Thompson, Pa. 

Ligation of the Anterior Tibial Artery above the 

Ankle Joint 131 

J. B. Carrell, M. D., Hatboro, Pa. 

A Short Umbilical Cord . . . . . .132 



SOCIETY REPORTS. 

The Surgical Society of Louisville 133 



CORRESPONDENCE. 

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EDITORIAL 

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House Quarantine 

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THE 

Medical and Surgical 
Reporter. 

No. 1874. PHILADELPHIA, JANUARY 28, 1893. Vol. LXVIII— No. 4 

ORIGINAL ARTICLES. 

LOCOMOTOR ATAXIA. 

E. H. TOWNSEND, M. D., New Lisbon, Wis. 



Locomotor ataxia is a disease dne to a 
lesion of the sensory portion of the spinal 
cord, associated from its onset with dis- 
turbed action of the exodic system. It is 
a chronic disease, extending over a long 
period of years (from five to thirty), and 
is commonly divided into three stages. 
First, invasion; second, incoordination; 
third, stages of complications. 

I would especially emphasize the fact of 
its long duration, as a case under my 
treatment for Bright's disease was diag- 
nosed by a physician, called during my 
absence, as locomotor ataxia, though the 
whole duration of the sickness was less 
than a year. Prof. Erb, of Heidelberg, 
in Ziemssen's Cyclopaedia of Medicine, 
says : " The duration of the disease is gen- 
erally very considerable, and is always to 
be counted by years, and sometimes by 
decades." Cases may go on to the stage 
of incoordination in a few weeks; when 
the symptoms will abate or remain quiet, 
for a long period. 

The present name and the impulse to 
study the conditions of this disease were 
given by Duchenne, though for years, it 
had been known as tabes dorsalis. 

When fully developed it is characterized 
by difficulty of walking ; disturbed action 
of the bladder causing slow and difficult 
micturition ; disordered action of the rectum 
causing constipation, with loss of visceral 
reflexes; followed, still further in time, by 
imperfect use of the upper extremities, and 
by impairment of the visual and auditory 
senses. Muscular power is not lost, but 



because of imperfect coordination of the 
muscles the error of making a diagnosis of 
paralysis occurs. 

The parts of the cord most commonly 
involved, are the columns of Gall and 
Burdach, the disease being confined, in 
the first stage, to the dorsal and lumbar 
regions. It is only when the cervical 
region becomes diseased that the upper ex- 
tremities are affected, and the pupils be- 
come contracted and fail to respond to 
light. 

There are severe pains of a light- 
ning-like character, — compared by many 
to the insertion of a knife or sharp instru- 
ment into the flesh of the parts, — especi- 
ally of the lower extremities. The stomach, 
rectum or bladder may be affected and, in 
the early stage, dyspepsia, hemorrhoids or 
stone in the bladder may be thought of. 
These pains are common in the first and 
second stages, and may be present in the 
third. Ataxia is differentiated from rheu- 
matism or neuralgia by the pangs being 
momentary in duration and, unlike the 
pains of rheumatism, do not attack joints, 
cause swelling or stiffness, but attack 
small local areas, usually between joints, 
and are not often repeated in the same spot. 
Nor do they, as in neuralgia, follow the 
distribution of nerves, nor along nerve 
trunks, nor have sensitive points upon pres- 
sure along the course of the affected nerve. 

Again the pains of neuralgia are referred 
to the skin, those of ataxia to the deeper 
structures. Also the latter are confined 
mostly to the lower extremities and ab- 



120 



Original Articles. 



Vol. lxviii 



dominal viscera, while neuralgia and rheu- 
matism attack any part of the body. The 
skin is for a short time after the attack, 
tender over the spots of pain, but the 
most common sensation is that of anaesthe- 
sia, — a feeling as if the feet were in cold 
water; as if the soles of the feet were 
covered with mud or felt; a feeling of 
tingling, pins and needles, or as of insects 
creeping under the skin. The light touch 
of a pin, hair, or thread may not be felt, 
while there is pain upon firm pressure. 
Delayed conduction of sensation is one of 
the marked symptoms of this stage. The 
prick of a pin, which should be conveyed 
to the brain in health in about one twenty- 
third of a second (sensation traveling, as 
per Flint, eighty-seven feet per second), 
is perceptibly delayed. Gowers cites a 
case, in his practice, of sensation being- 
delayed seven seconds; in another case 
(Eulenberg) a delay of fifteen seconds. 
In many cases the pain will increase for 
several seconds after being felt, and will 
last for several seconds after the exciting 
cause is removed. 

After a period of a few months, — or it 
may be many years, — comes the stage of 
incoordination of muscular movements. 
These are usually manifested in the gait 
because, as before said, the lesion is, at 
this stage,in the lower segments of the cord. 
The loss of patella reflex and ankle-clonus 
is* now marked, although in part absent 
from the onset of the disease. If the dis- 
ease, at this stage, involve the cervical 
region, there will be incoordination of the 
upper extremities which can be tested by 
asking the patient to write or place their fin- 
ger upon nose, eye or ear, or to button and 
unbutton their clothes. While the gait 
is labored there is no paralysis ; the power 
of the individual muscle remains while the 
power for several muscles, or groups of 
muscles to act in harmony is lost. One 
of the first things a patient notices is the 
inability to put his feet upon small objects 
or to lift them to place them upon a stair, 
chair or stirrup. One patient I had, com- 
plained that he could not wash his face 
with his eyes shut. 

After a time the patient will stand 
with the feet wide apart the better 
to keep the balance. Locomotion 
in the dark, or the hurried crossing 
of a street, causes a sense of insecurity — 
the visual sense being necessary to direct 
the movements. A cane now becomes 



useful to preserve the balance. As inco- 
ordination increases, the power to stand 
with feet together, though the eyes be 
open, is lost. The patient now walks 
slowly, with determination and delibera- 
tion, with a jerky, stamping motion, the 
heel coming to the ground first. Move- 
ments of the legs are sometimes unex- 
pected ; the toes and foot are thrown out- 
ward, and the patient falls. The motion 
of the limbs in walking has been compared 
to the swinging motion of a tight-rope 
performer. The soles of the feet have be- 
come deprived of sensation, and the anes- 
thetic condition has extended upward 
along the legs and thighs which may be- 
come dead to all sensation. Dr. Eanney 
used to teach, and insist upon this fact 
emphatically, that the symptom thought 
(by so many physicians) to be pathognomo- 
nic of ataxia, — staggering or falling when 
standing with eyes closed or upon walking 
backward, goes for naught unless joined 
with many other symptoms which are 
common ; and that no test is more worth- 
less for this special affection. A patient 
of his, whose feet were severely frozen, 
would fall because of the loss of sensation. 
And the condition of staggering or falling 
is found in hysterical paralysis, hysteria 
and myelitis of the posterior horns. A 
case of hysterical paralysis came under 
my notice two years since, which had been 
diagnosed as ataxia upon this symptom 
alone, — the patella reflex was present; 
lightning pains absent; sight and hearing 
abnormally acute. Intracranial diseases, 
such as Meniere's disease, or attacks of 
auditory vertigo, cause staggering. Hence, 
as in all cases of complicated disease, 
diagnosis by exclusion is the only true and 
safe way to reach conclusions. 

A painful sensation, as of a rope or belt 
fastened tightly about the waist or body, 
is often present. This is called the cincture 
feeling and its location, in a measure, 
determines the parts of the cord involved ; 
remembering, however, that the nerves, 
as they pass out of the vertebral canal 
below the first lumbar vertebra (the cord 
not extending lower than this), increase 
the length of their roots; the lumbar, 
sacral, and coccygeal nerves increasing 
from nerve to nerve by the thickness of a 
vertebra. 

It is stated that in five-sixths of the 
cases where the eye is affected, the re- 
flex action of the iris to light is lost. 



January 28, 1893. Original Articles. 



121 



Atrophy of the optic nerve is the most 
serious of the eye complications in tabes ; 
of this complication, however, I know 
nothing. 

There is also, in the third stage, ver- 
tigo and deafness. The functions of the 
other cranial nerves are not affected. 

The complications are the causes of 
death, — ulcers; herpes; perforating sores, 
of the foot; retained ucine with ammoni- 
acal decomposition; cystitis from use of 
catheter; fecal poisoning from retained 
feces; changes in nutrition of bones and 
joints. One case, which I have, has two 
large sores where his knees rub together, 
and he is obliged to keep them apart by 
cushions. There is sometimes vomiting 
in the gastric crises, of the peculiar ex- 
pulsive character seen in brain troubles, 
— without warning and without nausea. 
Bed-sores, urinary troubles, and passive 
pneumonia in bed-ridden subjects, are 
frequent causes of death. As syphilis 
is one of the common causes of the dis- 
ease, gummata, or syphilitic disease of cere- 
bral vessels causing apoplexy, may occur. 
The disease itself is not fatal, many pa- 
tients remaining bed-ridden for a long 
period of years. 

Eichorst gives, in tabulated form, the 
more important symptoms, quoting the 
following authorities : 





Bernhart. 


Erb. 




58 i 


3ases 


46 eases 


Absence of patella-reflex 
Lancinating pains 
Paresis of bladder 


100.0 


per ct. 
tt 


98.0 per ct. 


79.5 


92.5 " 


74.1 


<< 


81.0 " 


Delayed conduction of pain 


84.4 




89.5 " 


Feeling of exhaustion 


92.0 


M 


97.9 " 


Ataxia 


94.1 


tt 


100.0 " 


Sexual Weakness 


43.7 


tt 


78.5 « 


Swaying and tottering with 








closed eyes 


90.2 


(( 


83.5 " 



Pathological Anatomy shows sclerosis of 
the whole posterior column. This ex- 
plains the cause of delayed sensation, the 
sclerosis causing such pressure upon the 
sensory nerve filaments as to partially or 
completely destroy the axis cylinders. 

Etiology. — Ataxia is found more fre- 
quently in city than in country life; in 
families of a neurotic tendency, manifest- 
ing such diseases as insanity, epilepsy, and 
degeneration of the nervous system. Ex- 
posure to cold and dampness,traumatism of 
spine, sexual excesses, syphilis, and some 
acute blood diseases are accredited causes. 

There is quite a difference of opinion as 
to syphilis being a cause. Some contend 
that, if it were a factor, no particular part 



of the cord would be singled out, but any, 
or all parts would be affected alike ; also, 
that the most energetic antisyphilitic 
treatment does not effect a cure, while it 
usually cures in paralysis from brain le- 
sions of syphilis. Others contend that it 
is one of the most common causes. 
Hutchinson, the great English authority 
on syphilis, in a recent lecture, says: — 
'"There are certain affections which ap- 
pear to be related to syphilis, although 
not directly dependent upon it, in which 
it is a predisposing, though scarcely an 
efficient, cause. Among these I count lo- 
comotor ataxia and paralysis of the insane. 
We seldom see ataxia excepting in those 
who have had syphilis." Gowers cites 
fifty consecutive cases in which twenty- 
nine, or fifty-eight per cent, had definite 
histories of syphilis. 

Men are more prone than women to 
ataxia, in the proportion of ten to one, 
showing something in the sex predisposes 
to it. Possibly due to a man's occupa- 
tions ; to exposure ; to cold and dampness ; 
to drink and sexual excesses ; as, also, to 
accidents which harm the spine. It some- 
times follows acute blood diseases, inflam- 
matory rheumatism, etc. It is a disease 
of middle life, rarely occurring during 
childhood or after the fiftieth year of age. 

Prognosis. — G-owers, Eanney, Horsley, 
and Hamilton claim that some cases can 
be cured, and we know the great majority 
can be relieved by proper treatment. If 
it prove fatal, it is from some intercurrent 
affection. The duration of the disease is 
undefined. Sometimes the second stage 
is never reached, but even with complica- 
tions some cases last from five to thirty 
years. 

Treatment. — In the first stage, if we are 
consulted, we should remove all known 
causes, such as excessive mental work, 
anxiety and physical fatigue, since they 
are harmful; and we should insist upon 
perfect rest. Care should be taken to 
avoid anything tending to depress the 
nervous system. If exercise be taken, it 
should be short of fatigue. Care should 
be taken to avoid jolting or concussion of 
the spine. Cold is very injurious, and 
exposure to a chill results in a rapid in- 
crease of the disease. In a medicinal way 
the digestion and bowels should be at- 
tended to. One of the best known reme- 
dies to aid digestion and assist the free 
action of the bowels and kidneys, is the 



122 



Clinical Lectures. 



Vol. lxviii 



free use, one and one-half hours before 
eating, of from one to two glasses of hot 
water. It causes peristaltic action of the 
bowels, washes out the stomach, increases 
the flow of urine and the action of the 
skin, and soothes the terminal filaments 
of the nerves of the stomach. The water 
must be as hot as can be borne. Ergot, 
one drachm three times a day, combined 
with some of the bromides most easily 
taken ; citrate of lithia, and, most import- 
ant of all, the actual cautery, are valuable 
remedies. Total arrest of the disease and 
of pain has followed the last named proced- 
ure. "When there is intense pain, hypo- 
dermic injections of morphine or the in- 
ternal use of Codeine, are of service. In 
the second stage the bromide should be 
stopped. Should there be the least his- 
toiy or suspicion of syphilis, the mercury 
and chalk mixture, (which, Hutchinson 



says, " is the only form in which to use 
mercury for a long time"), which we also 
use in the first stage, should be continued. 
Nitrate of silver in pill form can be used, 
not pushing it, however, to the extent of 
staining the skin. Static electricity, cau- 
tery, and, if the bladder be affected, bella- 
donna should be used. Hammond advises 
.the injection of atropia. Suspension, 
causing separation of the vertebrae, is 
highly recommended, but the results have 
not proved as beneficial as at first re- 
ported. If there be any retained urine, 
the catheter should be used. The bladder 
should be washed out with a fountain syr- 
inge and soft catheter, which the patient 
can be easily taught to use. Arsenic is a 
very valuable remedy; used best in the 
form of Fowler's solution. Bed-sores and 
all other complications should be watched 
for and treated as they arise. 



CLINICAL LECTURES. 



TUBERCULOSIS OF THE SHOULDER JOINT; TONSILLOTOMY; 
TUBERCULOSIS OF THE HIP JOINT. 



JOHN B. HAMILTON, M. D., LL.D., Chicago* 



TUBERCULOSIS OF THE SHOULDER JOINT I 
RESECTION BY A NEW METHOD : 
TEMPORARY RESECTION OF THE 
ACROMION. 

Gentlemen : The first case that I shall 
present to you to-day is one of tuberculosis 
of the shoulder joint. 

Tuberculosis comes to this clinic so often 
that it is hardly worth while for me to go 
into the details of the pathology of the 
affection further than to say, that it con- 
stitutes, roughly speaking, about ten times 
as many cases of disease in this clinic as 
come from any other single cause — that is 
in the form of tuberculosis of bones, 
joints, glands, or some portion of the 
body. 

In the case of the patient before us we 
have a sinus on the anterior border of the 
axilla, and another one posterior to the 
axilla at its outer border ; each of them 
extending directly upwards for three and 
a half to four inches on either side of the 

* Professor of the Principles of Surgery and Clinical 
Surgery, in Rush Medical College. 



humerus. I cannot pass a probe directly 
into the shoulder joint, and yet I have no 
doubt that the pus in this case proceeds 
from the shoulder joint. This man seems 
generally sound, but we notice atrophy of 
the muscles of the arm. The right arm 
itself is helpless as compared with its fel- 
low. And for nine years the patient has 
had these two openings, at times closing, 
at others breaking out and an abundance 
of pus being discharged through these 
fistulous tracts. 

It can be but one thing. We might 
have, it is true, a foreign body, such as a 
projectile from a pistol, or a gun-shot 
wo and in the head of this bone, but the 
history of the case shows there has been 
nothing of that kind. He states that 
about nine years ago he received a bruise 
on the shoulder over the deitoid muscle. 
But there is no apparent connection be- 
tween that bruise and the existing sore, 
except sometimes we know that tubercu- 
losis which is latent, is suddenly lit up, 
propagated and developed by mechanical 



January 28, 1893. Clinical Lectures. 



123 



violence, or is produced by irritation of 
some sort, 

We are confronted with the problem to- 
day, how best to stop this constant drain 
of the system without seriously impairing 
the joint. On examination I find he is 
able to raise a chair with his hand. He 
can raise the elbow nearly to a level with 
the shoulder but the arm* is disabled al- 
most totally. We must plan an operation 
in this case which will not deprive him of 
the use of the arm, at the same time we 
must destroy the pyogenic center. 

I propose then to make an exploratory 
operation. 1 shall cut down by the 
method proposed by my colleague, Prof. 
Senn, in his recent work on ' ' Tubercu- 
losis of Bones and Joints," making a tem- 
porary resection of the acromion. So far 
as I know, no surgeon has as yet per- 
formed it. We will test its feasibility at 
this time ; make the operation, and ex- 
pose the portion of the joint surface that 
is the probable seat of the disease. 

In making a resection of the head of the 
femur, we take a chisel, lift up the tro- 
chanter, leaving its muscular attachment, 
so that when we cut off the head of the 
femur we can then return the trochanter 
and the rotation of the . limb is perfect 
when the trochanter again unites. I have 
a patient, at present under observation in 
the Presbyterian Hospital, who can turn 
his toes in and out as well as he could be- 
fore the head of the femur was removed. 
That is accomplished by preserving the 
muscles intact, making a temporary re- 
section. We do the same thing in the 
case of the olecranon and other bones. 

I shall, in this case, make a straight incis- 
ion, commencing just above the acromion 
process, extending through the skin, pass- 
ing a little backward toward the posterior 
border of the axilla. I shall then meet 
that with another incision, passing down 
toward the spine of the scapula. In this 
way I propose to fully expose the acromion 
process, and then make a temporary re- 
section of that process. This should ex- 
pose the capsule of the joint with the least 
injury to the soft parts. 

Several methods of opening this joint 
have been proposed and practiced. There 
are perhaps ten or fifteen different lines of 
incision. All of them are planned to 
avoid the great vessels of the axilla ; some 
are made on the anterior surface ; some 
directly through the deltoid on the ex- 
ternal surface. 



I shall first locate the acromion. Locat- 
ing it, we make a transverse iucision just 
above it and then a long one just behind 
the acromion, passing down along the ex- 
ternal border of the deltoid muscle; You 
will notice that the probe on the anterior 
surface passes directly upward for a dis- 
stance of three and a half to four inches ; 
there is another opening on the posterior 
border which passes in the same direction. 
So the inference is clear that the source of 
origin of this pus may be the shoulder 
joint. Please remember, that in this 
operation it is not proposed to detach the 
muscle from the bone. On the contrary 
we propose to preserve its bony attach- 
ment. 

I now with the chisel cut through the 
acromion process, and you will see that the 
attachment of the deltoid is practically un- 
touched. Theoretically we shall be able 
to come directly upon the capsular ligament 
and, as you will see, we shall be able 
to enter the joint from above. Observe 
that the pus cavity is directly under the 
acromion in this case and that I have now 
come upon the capsule of the joint. I 
shall open it and pass my finger over the 
joint surfaces. I must be careful, in open- 
ing the joint, not to interfere with the 
long tendon of the biceps, or the circum- 
flex nerve. In order to prevent that we 
shall determine where the biceps is located 
in its groove and, in order to throw it out 
of its position so far as may be, we will 
rotate, bring the humerus across the body 
and enlarge the incision. The portion of 
bone which you see is the acromion pro- 
cess of the scapula which I have turned 
up. The pus cavity I uncover when I lift 
the acromion. We probably do not see 
the extent of the carious process, so before 
proceeding to the more radical method of 
turning the head of the bone out, I will 
remove the pus. The difficulty attending 
this operation so far seems to be lack of 
room to fully expose the head of the bone. 
I will increase the room by farther turning 
up the deltoid flap. We are now breaking 
into pus cavities all about this joint. The 
head of the humerus is now well un- 
covered, or rather the external face of it is. 
We will separate the attachments from the 
glenoid cavity by throwing the arm 
directly across the body, then making 
rotation outward. The bicipital groove is 
now exposed to view. I shall cut the fas- 
cia and the tendon sheath so as to loosen 
the biceps along the groove and not cut it, 



124: 



Clinical Lectures. 



Vol. lxviii 



for by so doing the circumflex nerve 
should be thrown over with it. 

Pus comes directly out of the bone the 
minute the chisel strikes it. We have to deal 
then with a case of tubercular osteomy- 
elitis of the head of the humerus. The 
bone is very soft. The head of the humerus 
is honeycombed with pus, and so soft that 
the slightest touch suffices to break it 
down. You will see that the exposure of 
the joint has been perfect. Prof. Senn's 
theory has been carried into practice here 
with success so far as reaching the joint is 
concerned, which, of course, is the main 
thing. 

I have now scraped out the carious bone, 
removed the head of the humerus and 
shall smooth the glenoid cavity, which 
seems to have been infected, pack it with 
iodoform gauze and then clean it out. 
First rub it well so as to have the iodoform 
fully penetrate it. Fill these surfaces 
with iodoform powder, so that any tuber- 
cular deposit, which may have escaped 
being scraped out, shall be reached by it. 
I now take the soft parts that are involved 
in the disease and scrape the pyogenic sur- 
face so as to leave the tissues exposed to 
view. We will pack the cavity with iodo- 
form gauze, carefully and tightly, and 
leave one end projecting at the most 
dependent portion of the wound, so that 
we can remove it at pleasure, and it will 
at the same time serve for drainage. I 
shall now tie the vessels if they seem to 
require it, which they do not, and then 
bring back the deltoid and suture the 
acromion section which was made. It is 
a temporary resection. The deltoid is 
preserved. 

This man will be able, hereafter, to 
raise the arm precisely as he could before 
the operation, which is the particular 
point to be gained by a temporary resection 
of the acromion. I passed the needle 
through the fascia covering the bone and 
through the periosteum on each side of 
the incision, so we are bound to bring the 
acromial surfaces directly in apposition. 
If I had this operation to do over again, I 
should throw back the deltoid and dissect 
it off from the face of bone in the begin- 
ning. This would shorten the operation 
one-half. 

On examination of the removed bone, 
we find that the pus originally came from 
the centre of the head of the humerus. You 
can see it as a pulpy mass, evidently tu- 



berculosis of the humerus. The tissues 
immediately about were little involved ex- 
cept that they afforded depots and an out- 
let for the pus. At the point where the 
drainage is inserted I shall put in tempo- 
rary sutures, leaving a long loop so that 
they may be tightened subsequently, con- 
stituting what is termed secondary sutures. 
I shall now complete the operation by 
passing a small-sized sharp spoon into each 
of these original openings and scrape out 
the fistulous tract. The upper end of it 
was thoroughly done when the flap was 
turned up. I am satisfied that this oper- 
ation will be one of the most common for 
reaching the joint. It is very easy of 
performance, and I believe it will be found 
to be more successful than others. The 
wound is to be thoroughly cleansed ; the 
arm fixed to the side; cotton and gauze 
placed next to it, and then by a plaster- 
of-Paris roller the shoulder is fixed in po- 
sition for three weeks. We may cut a 
fenester in the plaster if we find a rise in 
temperature, but if there be no elevation 
of temperature the first dressing will 
remain for a period of one week. 

TONSILLOTOMY. 

This child has a sore throat and a swol- 
len tonsil. I have here the tonsillotome 
of Fahnestock. It consists in a ring 
with a double spear for fixing the tonsil 
and a guillotine blade which pushes 
through when the tonsil is fixed. It is 
intended for the partial removal of the 
gland when it becomes permanently hyper- 
trophied. I think the surgeon is not jus- 
tified in removing tonsils when swollen, 
and in a state of acute inflammation. 
But when they become permanently hy- 
pertrophied, and the condition has existed 
for some time, and there is no longer any 
probability that the gland will resume its 
normal size, then the surgeon is justified 
and should remove the projecting portion 
of the tonsil. I prefer in my office, when 
I am required to do the operation, to take 
a volsella forceps with the claws at the 
side, open the mouth, seize the tonsil, 
and cut it off with a curved bistoury — a 
more surgeon-like instrument than this 
machine I am now using. 

TUBERCULOSIS OF THE HIP JOINT TEM- 
PORARY RESECTION" OF THE 
TROCHANTER. 

I have not recently examined this child 
and I do not know, therefore, what opera- 



January 28, 1893. 



Clinical Lectures. 



125 



tion will be performed, but we will find 
out as soon as the examination is com- 
pleted. 

She has been in the hospital several 
times ; sometimes having extension appa- 
ratus applied, at other times remaining in 
bed with weight and pulley. But all of 
that kind of treatment, which is simply 
palliative and intended to hold the joint 
surfaces apart while the child is under 
tonics and other means of treatment, has 
been without avail. She now comes back 
to the hospital unable to walk, unable to 
move the hip without severe pain — so 
painful in fact that I propose to conduct the 
examination under anaesthesia, perform 
whatever operation is required and can be 
done at this time. 

On turning the child on the side you will 
notice a fistula posterior to, and a little 
below the trochanter. We will take the 
probe and ascertain the direction of the fist- 
ula. I find that the probe passes directly 
into the joint. There is, therefore, only one 
way to treat this joint successfully at this 
stage, that is, to make an opening into it, 
remove either the soft parts by arthrec- 
tomy, or resection of the bone, or both, ac- 
cording to the extent of the disease. If 
this girl were an adult instead of a 
child, there would be no objection to per- 
forming a typical resection, but in chil- 
dren an atypical one should be the rule. 

I will content myself by cutting down 
upon and performing a temporary 
resection of the trochanter. We simply 
cut down upon it by linear incision, with 
the chisel lift it up with its muscular at- 
tachments, and the neck of the femur is 
fully exposed. We are then able to reach 
the joint. I make my incision directly 
over the trochanter, slightly curved, but 
passing deeply down to the bone. I have 
separated the soft parts from the bone as 
much as is required to make a linear in- 
cision to the trochanter. I have separ- 
ated the trochanter from the femur with the 
chisel and the incision is directly on a level 
with the upper surface of the neck of the 
femur. I shall turn the trochanter directly 
upward, which gives complete access to 
the capsule of the joint. I now separate 
the neck of the femur from its attach- 
ments, open the capsule and expose the 
joint. Now, by rotating a little, I can 
put my finger directly iuto the opening 
and feel the amount of erosion that exists, 
with the head of the bone still within its 



socket. If it be not too great, I prefer to 
do but little else than to make an opening 
into the joint and provide for the injec- 
tion of iodoform. 

Eemember what I have previously said 
about resection in children. We avoid 
them whenever possible, as we stop the 
growth of bone by resection; whereas, if 
we can perform an arthrectomy, or, by 
gouging out the carious portions of the 
bone preserve the joint, we will have ac- 
complished, very much more for the child. 

I find a sinus with a roughened surface 
on the face of the bone, and I shall gouge 
out this opening first, as the bone is quite 
soft. I shall be able to do ,it without 
using the knife. This is being done sub- 
periosteally. I am passing a gouge longi- 
tudinally along the neck of the femur to 
the head of the bone, and removing the 
carious surface, which I will soon have com- 
plete access to, piece by piece. The pus, 
which is very plentiful here, exudes from the 
bone in several places, and we have, as in 
the shoulder case, evidence of its com- 
mencement in the medulla of the bone and 
its cancellous structure. I find that the 
acetabulum itself is involved, and the rim 
of the acetabulum will have to be scraped 
out. This I am doing. The process is 
tedious. In the removal of these frag- 
ments of bone you will find it expedient 
to use the finger as a guide, keeping it on 
the fragment while the instrument (the 
sharp spoon) is being fixed. In this way 
you avoid unnecessary damage to the soft 
parts, and it enables you to have control 
of the operation at nearly all of its stages. 
The specimen which I show you, as now 
removed, consists of half of the side of 
the neck of the femur and half of the 
head. You will see how the disease has 
progressed around the head of the bone. 
The white, glistening portion is the artic- 
ular surface of the head of the femur; the 
eroded portion of the other side is where 
tuberculosis has eaten into the head of the 
bone. We now irrigate the joint as there 
is a great deal of eroded surface; the 
wound is dusted with iodoform powder, 
and, as before, iodoform gauze is inserted 
for drainage. There is a sinus under- 
neath the bone in the soft parts extend- 
ing into the cavity of the acetabulum, 
which I thoroughly scrape with the sharp 
spoon. I now bring the trochanter back 
into its place, leaving a drainage of gauze 
from the most dependent portion of the 



Communications. Vol. lxviii 



126 

wound which passes directly into the 
joint. We sew the trochanter into posi- 
tion with very heavy catgut. I pass a 
needle through the periosteum, the fascia 
and sheath of the muscles attached to the 
trochanter and through the same struc- 
tures on the shaft of the femur, thus 
bringing the parts into perfect apposi- 
tion. The power of rotation of this 
child's thigh when the trochanter and 
bone unite, which will be in about three 
Aveeks, will be as perfect as before the op- 
eration. Care should be taken that no 
tension is put upon the stitches that can be 
avoided. The limb should be fixed in a po- 
position which brings the bone together 
without tension. The packing, which is 
being inserted, is in the intermuscular sep- 
tum where the pus formed during the prog- 
ress of the disease, and which has been thor- 
oughly scraped and irrigated. You will 
notice there has been very little hemor- 
rhage. Hemorrhage is much less when 
the trochanter is resected than in the 
other operation. 

The dressing in this case will be pre- 
cisely as in the former one. The parts 
about the wound are to be well cleansed ; 
iodoform gauze and antiseptic absorbent 



cotton applied, and a plaster cast over 
all. 

The history of these cases after resec- 
tion of a joint, performed as these were, 
is generally one of uninterrupted convale- 
scence. Occasionally we have a sinus 
formed directly in the tract of the wound, 
due, undoubtedly, to some pyogenic re- 
formation, — some bacterial colonies which 
were left in some undisturbed pocket at 
the time of the operation. But in the 
majority of cases we do not expect any re- 
sult other than steady progress toward un- 
interrupted convalescence. It is a crip- 
pled limb, but it was this before the oper- 
ation was performed. We have stopped 
the pus formation. More than that, it 
differs from an ordinary resection in this 
particular: after the old methods of 
resection, the limb hung like a flail; 
while it might be as powerful as before, 
especially after resections of the head of 
the humerus, yet the power of rotation 
was completely lost; and in many in- 
stances the power of elevating of the el- 
bow to the level of the shoulder was lost. 
In our case of temporary resection of the 
acromion, I have no doubt the power will 
be as perfect as before the operation. 



COMMUNICATIONS. 



TECHNIQUE OF SUPKA-PUBIC CYSTOTOMY. 

JAS. S. CHENOWETH, M. D., Loihsville, Kr. 



I would like to present as a basis for 
discussion, a few points relative to the 
technique of supra-pubic cystotomy. I 
have been impressed, in all of these opera- 
tions that I have seen, with the importance 
not only of a strict regard for the indica- 
tions to be met in each individual case, 
but also with the importance of a strict 
attention to detail in meeting them, if we 
would receive the greatest possible good 
from our operation. 

Viewed from the standpoint of the tech- 
nique, I think we can properly divide our 
cases into four general classes. 

The first class includes the recent cases 
of stone and foreign bodies and small 
pedunculated growths, where the bladder 
is only moderately or not at all diseased. 

The second class includes the neglected 
cases of the first class, where severe in- 



flammatory changes have taken place in 
the bladder walls. 

The third class includes the cases re- 
quiring removal of tumors or prostatic 
outgrowths, or prolonged drainage for 
cystitis. 

The fourth includes that not inconsider- 
able number of old neglected strictures of 
the urethra in which a guide cannot be 
passed for the perineal operation, and re- 
trograde catheterization of the urethra is 
desired. 

In the first class, no especial preparatory 
treatment is requisite beyond emptying the 
bowels by laxatives and enemata, irrigat- 
ing the bladder with boric acid solution 
and shaving and cleansing the abdomen. 

The anaesthetic — preferably chloroform 
— being administered, an oval rubber bag 
with the tube attached is introduced into 



January 28, 1893. Communications. 



127 



the rectum. By means of a soft catheter 
and a hand syringe the bladder is filled 
with warm boric or Thiersch solution, the 
quantity being regulated by the known ca- 
pacity of the bladder and the sense of re- 
sistance imparted to the hand; this is re- 
tained by an elastic band around the penis 
and a clamp on the catheter. The rectal bag 
is now slowly and carefully injected and 
the bladder may be felt in contact with the 
abdominal wall above the pubis. A three 
inch incision in the median line, just 
above the pubic bone, carried down between 
the recti and pyramidalis muscles exposes 
the prevesical space and the presenting 
bladder wall covered by a thin membrane 
containing more or less fat. This fat, 
which contains the peritoneum, is rolled 
up from the symphysis, care being taken 
not to disturb the lateral attachments of 
these loose tissues. This little manoeuvre 
is often much abused, and operators, in a 
frantic effort to avoid the peritoneum 
which is in no danger if the bladder and 
rectum have been properly injected, so 
loosen up the attachments behind the 
symphysis and around the neck of the 
bladder that urinary infiltration and con- 
sequent cellulitis is inevitable. 

The bladder being exposed, any large 
veins on its surface in the line of pro- 
posed incision are ligated with fine catgut 
by means of a sharply curved needle; and a 
strong silk ligature is passed deeply into 
the wall of the bladder, which is incised 
just below by a clean thrust of the knife. 
This ligature serves to hold the bladder 
in contact with the abdominal wall after 
the incision, and diminishes the risk of 
tearing loose the anterior attachments 
while punching around in the bottom of 
the pelvis trying to find the opening in the 
now collapsed organ. 

The incision in the bladder should be of 
sufficient length to permit of the easy re- 
moval of the foreign body without tearing 
and bruising the edges of the cut. Guided 
by the ligature the finger is quickly intro- 
duced and the body removed. After 
thorough irrigation the bladder, being- 
still held up and steadied by the ligature, 
is closed with numerous interrupted 
sutures of over prepared catgut carried 
down to the mucous coat; or in some cases, 
an oval surface may be denuded around 
the incision and the broad, fresh surface 
thus formed united by two rows of con- 
tinuous suture. A small drainage tube is 



laid over the line of suture and brought 
out of the lower end of the external wound, 
which is closed down to this point. A 
soft catheter introduced through the 
urethra and tied in, completes the opera- 
tion. 

In the second class, with inflamed, con- 
tracted bladders, effort should be made to 
cleanse them and at the same time gradu- 
ally dilate them to a reasonable capacity 
before operation, and unusual care should 
be taken against rupture when the final 
distension is made under anaesthesia. 
The operation is completed as in the for- 
mer class up to the point of closing the 
bladder wound. 

It being evident that the wound of an 
acutely inflamed and contracted bladder 
will not unite primarily no attempt should 
be made at closure, but drainage should 
be free. This may be done by a tube 
carried to the bottom of the bladder and 
retained by fastening to the skin, or by a 
perforated hard rubber plate with straps 
carried around the abdomen. The end 
of this tube may be left long and drain 
into a vessel at the bed side. If the tube 
causes much pain and is forced out it is 
often impossible to replace it; this seems 
to be of little moment as far as the blad- 
der is concerned, as it will drain and can 
be thoroughly irrigated without it, but 
the patient is kept continually wet by the 
flow of urine. 

In the removal of tumors or prostatic 
outgrowths from the bladder by the supra- 
pubic method, the rectal bag should be 
distended as far as safety will permit, thus 
forcing up the base of the bladder and 
greatly facilitating the work. 

The Trendelenburg position is also of 
great service here, bringing the parts well 
into view. After the removal of these 
growths there always arises the necessity 
for thorough drainage for a considerable 
length of time, and, in the case of old 
cystitis, the drainage may have to be per- 
manent. This drainage, in my experience, 
cannot be well accomplished without fas- 
tening the bladder to the abdominal wall. 
The tube almost invariably slips out, or 
has to be removed on account of clogging 
or becoming encrusted with urinary 
salts, and it is often impossible to replace 
it through the long sinus running down 
to the bladder. This sinus contracts 
rapidly and, unless the obstruction at the 
bladder neck has been perfectly removed, 



128 



Communications , 



Vol. lxviii 



the cystitis will return, and not only will 
there be no benefit derived from the oper- 
ation, but a small discharging sinus will 
add misery to an already miserable being. 

In opening the bladder for retrograde 
catheterization of the urethra in imperme- 
able stricture the rectal bag should not be 
used. The bladder is usually diseased and 



distended and the danger of rupture is 
great. A little care in stripping up the 
prevesical fat is all that is needed to avoid 
the peritoneum. The opening should be 
small and, as a rule, immediate suture 
practised, free drainage being kept up 
through the perineal opening until union 
is complete. 



NUKSING IN TYPHOID FEVER. 

JOHN C. HOLMES, M. D., Cranbury, N. J. 



To the country physician the nursing of 
typhoid fever is of particular interest, as 
he so frequently has considerable difficulty 
in obtaining a competent nurse in fever 
cases. 

There is no disease in which,, during the 
entire course, every organ of the body is 
so liable to become disordered as in ty- 
phoid fever. Therefore good nursing and 
particular attention to all of the minor de- 
tails is absolutely essential. 

When a case of typhoid fever occurs in 
a family, the first step to be taken is to 
isolate the sick person as much as possible 
from the rest of the household; this is 
necessary for two reasons, first, for the 
comfort of the patient, and secondly, for 
the safety of the other members of the 
family. 

A large room should be selected, and 
one which will afford means of perfect 
ventilation. 

The windows should be raised about 
four inches, and a board fitted tightly at 
the bottom, thus giving a free access of air 
over the top of the lower sash, and avoid- 
ing all draft. 

This ventilation should be continued 
day and night, even in the coldest weather. 
A uniform temperature should be main- 
tained from 60° to 70° F. 

In winter an open fire place or grate is to 
be preferred to any other method of heat- 
ing a sick room. Let the patient have as 
much covering on the bed as is necessary, 
but keep up the free ventilation at all 
seasons of the year ; fever patients are not 
liable to take cold. 

Do not admit visitors at any time during 
the course of fever — mental quiet is as 
necessary as bodily rest. Eemove all car- 
pets and curtains — in fact all that is re- 
quired in a " typhoid room " is the bed, • 



one chair, a small table and an alcohol 
lamp. Have a large covered clothes bas- 
ket in an adjoining room, in which all 
soiled linen may be at once placed and 
immediately carried out of doors; wash 
these clothes separately from the clothing 
of others, and direct the wash water to be 
emptied at a safe distance from the house 
and well. 

The sheets should be changed every day, 
and this can be done easily by folding the 
under sheet close to the patient, spreading 
one side of the bed over, and then gently 
lifting the person over on the clean side, 
at the same time removing the soiled and 
smoothing out the clean sheet. 

The aphorism, "cleanliness is next to 
godliness," is indeed truly hippocratic, 
and most assuredly applicable in typhoid 
fever. 

Twice a day wash the face, hands and 
limbs and, if advisable, even the entire 
body with lukewarm water to which add 
a little alcohol; in cases of extreme de- 
pression, alcohol or whiskey may be used 
alone ; a sheep's wool sponge is the best for 
use in washing the body of a sick person. 

All excretions from a fever patient 
should be received in a previously disin- 
fected vessel and at once removed out of 
doors, at least one hundred yards from the 
well and house, and there buried — a fresh 
layer of sand spread over each time. 

Now in regard to disinfectants, avoid 
carbolic acid on account of the unpleasant 
odor and the tendency to nauseate the sick. 
Piatt's chlorides is one of the very best 
disinfectants; it is perfectly odorless and 
can be procured at a very reasonable price. 
Chloride of lime, used according to the 
printed direction on the box, is always 
good. A solution of copperas can be used 
to wash out all vessels which receive the 



January 28, 1893. Communications. 



129 



excrement, and it is a good plan to leave 
some of this solution in the nrinal and 
bed-pan after they have been cleansed and 
returned to the sick room. 

As to light — do not keep a sick room in 
darkness (unless there should be brain 
complications) in fever or any other dis- 
ease — light and sunshine are as essential 
to the sick as to the well. 

If a lamp is used at night, do not turn 
the wick down, on account of the gas 
which will be sure to be thrown off, but 
shade the light so that it will not disturb 
the patient. 

One of the worst torments of fever is 
thirst, therefore give plenty of cold water ; 
little at a time but frequently. A 
swallow of water will moisten the mouth 
just as well as will a glassful. 

Drink should be given even when it is 
not asked for, as fever patients need just 
as much, and sometimes even more than 
when in health. Mineral water, lemonade 
and thin barley water are all exceedingly 
grateful. 

Keep ice in a covered vessel wrapped in 
a woollen cloth and in the next room, and 
always break the ice with a pin. If coal is 
used for fuel, put it in paper bags, and 
place it on the grate — thus you avoid a 
noise which is sure to attract the attention 
of the sick. 

Never attempt to use any force, or even 
to argue with a fever patient in order to 
have one take either food or medicine ; the 
sick are frequently very unreasonable, and 
if the mind is disordered it is worse than 
useless to endeavor to reason with them. 
When anything is refused put it aside at 
once and appear to be perfectly satisfied. In 
five minutes offer it again, and nine times 
out of ten it will be taken without any 
complaint. 

Never say to the sick, " now it is time 
to take your medicine," or " will you take 
the medicine now ? " — do not use the 
word medicine. Prepare it in silence, 
take it to the bedside, and say, gently but 
firmly, "swallow this please." It is not 
to be wondered at, that invalids have a 
feeling of disgust come over them when 
they hear the rattling of spoons and 
see the nurse making elaborate prepara- 
tions for the advent of each dose of medi- 
cine. I have seen the patient vomit at the 
sight of the glass and the noise of the 
spoon. 

Always remember that a sick person can 



never be spoken to too kindly; typhoid 
fever patients are frequently in a dreamy 
state of partial consciousness from which 
a harsh word would arouse them to the 
wildest frenzy. 

The nurse should be a veritable sphinx 
as far as all conversation is concerned. 
Questions should be answered in a mono- 
syllable, without any remark or comment. 

Always pretend to remove any imaginary 
thing from the room if so requested by 
the patient ; never declare that "it is 
nothing" ; you can not convince one 
with a disordered brain that an hallucina- 
tion is only imagination. 

Nourishment should be given at regular 
intervals, and the physician should not 
only give explicit directions as to the kind 
and quantity, but should make out a " time 
table " for both medicine and diet. 

The patient should never be allowed to 
have anything to eat or drink without the* 
permission of the doctor. There is no dis- 
ease in which the slightest indiscretion in 
regard to diet may prove so suddenly fatal 
as in typhoid fever — it requires but little 
to turn an almost evenly balanced scale one 
way or the other. 

Do not allow the patient to rise for any 
purpose whatever from the beginning of 
the disease until convalescent; many 
fatal cases of syncope have occurred upon 
assuming an upright position even for but 
a moment. 

Watch fever patients closely; never 
leave them alone — many apparently per- 
fectly manageable cases have jumped from 
a window, or committed suicide when left 
alone for a few moments by the nurse. 

It is best always to have two nurses, one 
by day and one for the night. Never 
trust the nursing to kind friends or good 
neighbors — who, while they may be over- 
flowing with sympathy, have not the 
routine of the case, and therefore can not 
do as well as a regular attendant. 

I have had seven cases of typhoid fever 
where I have found a new nurse on duty 
almost every day, and have frequently 
been unable to ascertain the exact condi- 
tion of the patient during the night, as 
the nurse "had gone home to get a little 
sleep," and left no other report of the case 
than this, " they were about the same as 
usual." 

If milk is used, keep it outside of the 
sick-room until it is required ; never allow 
milk to stand in a typhoid room of all 



130 



Communications. 



Vol. lxviii 



others ; prepare the exact quantity needed 
and use it at once — this direction should 
also apply to all meat-broths. 

Do not tell a fever patient any unpleas- 
ant news, — give them to understand that 
everything is going along nicely. 

Always speak encouragingly and hope- 
fully, giving the sick the benefit of every 
doubt. There is no disease in which a per- 
son can sink so low, to the very border 
and in the shadow of the grave, and still 
recover. 

Never "give up" a fever case, as 
changes for the better may occur when 
least expected, and even under the most 
unfavorable circumstances. I have seen 
cases which 1 feared would not live six 
hours, and have had the satisfaction of 
seeing them recover. Avoid all those 
people who make a business of " ntissin" 
they believe they know it all and are far 
more liable to overdo matters than really 



to neglect. Secure an intelligent man or 
woman, — one who has either an estab- 
lished reputation or a diploma from a 
training-school. 

Good nursing is, indeed, the sine qua 
non in typhoid fever — without it medi- 
cine is of little value. I would prefer an 
intelligent nurse and no medicine what- 
ever, rather than the attendance of an en- 
tire faculty and an ignorant or careless 
nurse. 

Human life is far too^precious to trust 
in the hands of unskilled persons; to err 
at such times is but too frequently fatal, 
and ofttimes the cause of life-long regret, 
which, while it may be without true cause, 
nevertheless may leave the unpleasant 
thought that perhaps something was left 
undone. 

The constant attention to all of the lit- 
tle things always gives the best results in 
nursing. 



A CASE OF CEREBRAL SURGERY. 



W. C. DUGAN, M, D., Louisville, Ky. 



I have a case of cerebral surgery that 
I would like to mention. A lady about 
fifty years of age has had great pain in the 
head for eight or ten months, and it has 
steadily increased. She has been treated 
by a number of physicians on various lines 
and she has grown steadily and rather 
rapidly worse. Her hearing was at first 
but slightly involved, but latterly to such 
an extent that she could hardly hear at 
all. During the last few weeks I am con- 
fident there has been marked impairment 
of intellect. 

I saw her for the first time several 
months ago, and then did not see her again 
for about two months ; meantime her phy- 
sician asked Dr. Dabney to make an ex- 
amination, and he reported double- choked 
disk, the right more marked than the 
left. Later she had partial paralysis of 
the right leg, twitching of the right side 
of the face aud incomplete loss of sensa- 
tion of the right arm. 

Diagnosis of tumor was made, its most 
probable location being in the left side 
about the upper part of the fissure of 
Rolando. She had two convulsions dur- 
ing this time, whether unilateral or bilat- 
eral I am unable to say, but they were 



rather severe and were followed by consid- 
erable stupor. Exploratory operation was 
advised for the purpose of finding the 
tumor, the understanding being if it 
could be removed it would be done. 

A very large semi- circular incision was 
made over the left parietal bone, the flap 
turned down leaving the periosteum in- 
tact. After going through the periosteum 
and turning it back separately, we took a 
large sized trephine expecting to take out 
a large button, but found it slow work, the 
skull being very thick. I then decided to 
take out a smaller sized button. The 
bone was removed and the membrane 
bulged up almost half way through the 
skull, very tense and feeling almost like 
wood. I then took a chisel and mallet and 
cut out the entire two inches of bone, the 
size of the original trephine. The tension 
was so great that the membranes came up 
almost on a level with the outer part of 
the skull. The dura was then incised and 
to my very great surprise, — and perhaps I 
should say my chagrin, — the brain just 
swelled up, almost like quicksilver, 
through the incision in the dura. There 
was a mass of cerebral tissue as large and 
thick as your finger pressed through the 



January 28, 1893. Communications. 



131 



opening in the dura, and the constriction 
was so great, and the tension from within 
so much, that it produced intense engorge- 
ment. The dilemma was not one to be 
envied, I assure you. I did not know how 
to close the dura. Knowing that there 
must be something to account for the 
great pressure, I explored with a hypoder- 
mic needle and found no fluid. I then 
took a groove director and passed it down 
to the ventricle, and found a large quan- 
tity of fluid in the left cavity — at least 
three ounces, and perhaps more. As the 
fluid flowed through the groove, the brain 
settled back in its place, and at the con- 
clusion of the aspiration I was able to pass 
my finger around the dura, palpating the 
brain so as to ascertain whether there was 
a tumor anywhere. No tumor was dis- 
covered. I then thought best to pass the 
groove director through the septum to the 
other ventricle to see if any fluid existed 
there. This was carefully done, but no fluid 
found. The dura was then closed, and 
the scalp sutured, no drainage being used, 
and the patient dressed and put to bed. 
She reacted well from the operation, there 
being no shock. 

She has had some little trouble since 
with loss of speech, but she is able to 
articulate some sounds distinctly and in- 
telligently. She has suffered very little 
pain since the operation, and has been 
doing very well. Instead of finding a 
tumor we discovered an accumulation of 
fluid in the left ventricle, the pathology 
of which I am unable to give. The fluid 
seemed to be perfectly clear, but whether 



it was tubercular or otherwise I am unable 
to say. The future of the case is purely 
one of conjecture; I am not prepared to 
say what the .outcome will be. Her phy- 
sical condition is good ; the operation was 
done one week ago, and she sat up to- 
night and is suffering no pain. The 
paralysis has been relieved, but her hear- 
ing has not returned. I cannot help 
believing that the trouble will return and 
that the end is not very far off. 

The paralysis was relieved immediately 
after the operation. Sensation now seems 
to be hyperesthetic. Before the operation, 
as she could not hear, her family would 
write messages on paper and she would 
look at it for a long time and eventually 
she would understand it. She would 
wait four or five minutes before answering 
a question, showing that her intellect wa 
greatly impaired. 

. I left the bone out for two reasons: 
First, it could not have been replaced, as, 
after taking out the button with the 
trephine, the opening was considerably 
enlarged with the chisel ; further I would 
have left the button out anyway so as to 
have the advantage of that amount of lack 
of resistance, and, in event of the fluid 
re-accumulating it can be aspirated with 
less trouble. The opening left in the 
skull, as nearly as I can judge, was about 
two inches in diameter. The only hemor- 
rhage experienced was from separation of 
the dura. If I had not explored the 
brain, I would never have been able to 
have brought the dura together. 



LIGATION OF THE ANTERIOR TIBIAL ARTERY ABOVE THE 

ANKLE JOINT. 



A. 0. STIMPSON, M. D., C. M., Thompson, Pa. 



Frank Allen, aged about thirty-three 
years, while chopping in the woods on the 
9th of December, 1892, accidentally made a 
deep cut with an axe in his right leg, 
about one and one-half inches above the 
ankle joint, and on. the outer side of the 
leg. The cut was apparently not a severe 
one, the incision being only about one and 
one-half inches long. He had on at the 
time a pair of felt boots (such as choppers 
and woodmen generally wear) and the axe, 
which was broad bitted with angular cor- 



ners, having a very thin and sharp edge 
penetrated the flesh much deeper than one 
would naturally suppose. 

After the accident his companions got 
him to the house as soon as possible, and 
resorted to ordinary domestic means to 
arrest the hemmorrhage, by bandaging 
and the use of " puff-balls " as a local 
styptic. 

No further difficulty was experienced 
with the wound until the next evening, 
when it commenced to bleed profusely. 



132 



Communications. 



Vol. lxviii 



I immediately applied the rubber tourni- 
quet over the popliteal space, using as a 
compress a rubber ' ' anti rattler " for 
wagon shafts. This controlled the hem- 
morrhage completely. I then tied the in- 
jured artery (anterior tibial) with an iron 
dyed silk ligature, But the operation, 
having been done by lamp light, was not a 
success. On December 11th (at night 
again) , a messenger came for me in great 
haste, saying that "Frank was bleeding 
to death." I hurried to the house and 
found that he had indeed lost so much 
blood that he was very weak. I immedi- 
ately applied the tourniquet in the groin. 
This checked the bleeding at once, but I 
concluded then I would wait until day- 
light before ligaturing the wounded artery. 

As soon as there was light enough, with 
the aid of a neighbor, 1 enlarged the in- 
cision upward toward the knee, and with 
a No. 11 iron dyed silk ligature I tied 
the artery the second time, using a sailors 
knot to prevent the loop from slipping. 

I had no trouble from hemmorrhage 
after that, but a wound remained that 
could only heal by second intention, or by 
granulation. In treating the granulating 
surface I used iodoform gauze, dry calomel 
and campho-phenique. 



A Short Umbilical Cord. 



J. B. CARRELL, M. D., Hatboro, Pa. 



On Dec. 28th, 1892, I delivered a 
woman, set 38, of her fifth child. There 
was nothing unusual about the case until 
I attempted to move the infant from its 
moorings. 

The child was drawn so closely to its 
mother that it was difficult to tie the cord ; 
in fact the second ligature was applied by 
pushing up the external genitals. When 
the cord was cut it disappeared up the 
vagina. I could not wrap the cord about 
my finger to make traction on account of 
its being too short; so I effected removal 
of the placenta, which had been expelled 
into the vagina with the expulsion of the 
child, by hooking my finger into the body 
of placenta and making external pressure 
with the other hand. Upon examination 
I found a cord seven and one-half inches 
long. 

This is not the shortest cord or) record. 
The shortest I find mentioned was two 



inches. Cazeau and Tarnier say: "The 
cord varies greatly in length at term ; gen- 
erally it is from twenty-one to twenty- 
three inches; some have been observed, 
however, from six inches to five feet; 
others, still more rare have reached five 
feet nine inches in length. I delivered a 
woman with the forceps, June 23rd, 1841, 
in whom the head had been retained above 
the superior strait, and where the cord was 
only nine inches long. These extremes 
are very rare; nevertheless, they are not 
the utmost varieties the cord may offer 
in its extreme limits, for it has been known 
not to exceed five inches, and has even 
been as short as two inches." With the 
expulsion of the child the placenta was ex- 
pelled from the uterus into the vagina. 
Had such not been the case, the short cord 
would have interfered with the delivery of 
the child. 



An exchange says that a new and sim- 
ple method of preventing bed-wetting by 
children is proposed by Dr. Von Trenton, 
who simple raises the foot of the bed so 
that the child lies on an incline with the 
opening of the bladder uppermost. This 
is based upon the theory that the urine 
escapes from the bladder while the child 
is asleep. The remedy is simple and 
worth trying ; the only difficulty is that 
most children have a natural fancy for 
rolling about in bed and will cause them- 
selves to sleep with the head at the ele- 
vated end of the bed as often as otherwise. 
— iV. West Lan. 



Sugar in the urine is no more a proof 
of diabetes than albumen is of Bright's 
disease ; and it is a great mistake to base 
the diagnosis upon the one point alone. 
The presence of the sugar may be due to 
transient nervous conditions, to tempo- 
rarily defective action of the liver, to ex- 
cess of sugar in the diet, as when a new 
clerk goes into a candy shop, or to a dis- 
turbance of the general system like that 
caused by the retention of the milk in 
woman who have suddenly stopped nurs- 
ing. G-out, syphilis, heredity and renal 
disease may also cause glycosuria without 
diabetes. Ord, of London, says that while 
he has not frequently met with carbuncle 
or phthisis in glycoruria, they are com- 
mon in true diabetes. — North Lan. 



January 28, 1893. Society Reports. 



133 



SOCIETY REPORTS. 



THE SURGICAL SOCIETY OF LOUISVILLE. 

Stated Meeting of December 12, 1892. 



The President, Dr. A. M. Oartledge, 
in the Chair. 

Dr. W. C. Dugan reported " A Case 
of Cerebral Surgery" (Page 130). 

TWO CASES OF STERILITY FOLLOWING GON- 
ORRHOEA. 

Dr. E. R. Palmer: A young man, 
having been married three years, came to 
me a year ago with gleet and stricture of 
the urethra, with the statement that his 
wife was barren; that he wanted to be 
cured; that his wife also had trouble 
which he believed she had contracted from 
him, and that he wanted me to treat her 
also. 

I operated on him for stricture by the 
Otis' operation, treating him for a long 
time and, at the same time treating his 
wife, who had chronic vaginitis and 
chronic endo-cervicitis with a deflected, 
fixed uterus, — a condition that we nearly 
always find where a woman had contracted 
gonorrhoea and the deeper membranes 
had been invaded. 

This man was entirely cured of his gleet 
and stricture. His wife was very promptly 
relieved, her vaginitis disappeared, the 
discharge from the uterus ceased and she 
was in excellent condition. I saw the 
gentleman a few days ago, and he said he 
was happy to report that he was the father 
of a fine girl. 

No. 2. About six months ago, when 
the pregnancy of the patient above referred 
to was well assured, another man employed 
by the same corporation, came to my office 
with his wife and asked me to make an ( 
examination, try to determine, why his 
wife never had any children, and treat her 
for barrenness. I told him this was rather 
out of my line, and suggested his consult- 
ing another physician. He said he had 
been married two years, and his wife had 
never conceived. As I had treated Mr. 
and Mrs. So and So, who had been married 
three years and the wife was pregnant, he 
wanted me to see what could be done in 
his case. I made inquiries as to whether 
either of them had ever had any trouble 
of a venereal nature, and he replied that 



they had not. I took them both over to 
Dr.. Anderson's office and they were ex- 
amined separately. 

The woman was a magnificent specimen 
of womanhood, weighing about 150 
pounds, apparently in perfect health, 
vagina and womb normal in position and 
size. In other words her entire sexual ap- 
paratus was in a perfectly normal condi- 
tion. 

I then took the man into an adjoining- 
room and he confidentially gave me the 
history that several years ago he had con- 
tracted gonorrhoea with double epididy- 
mitis, but stated that he had been cured 
for a long time before marrying. I in- 
structed him to have connection with his 
wife and bring me some of the semen for 
examination. He did so and it was found 
to be utterly devoid of spermatozoa, prov- 
ing beyond all question why his wife had 
never become pregnant. 

It is stated that in ten cases of barren- 
ness the woman is at fault seven times, 
the man three. 

Dr. Jas. S. Chenoweth read an essay 
The Technique of Supra-pubic Cys- 
totomy (Page 126). 

DISCUSSION. 

Dr. W. 0. Roberts: I have had con- 
siderable experience in the operation of 
supra-pubic cystotomy for stone, for 
cystitis, for tumor and for draining the 
bladder in old cases of enlarged prostate. 
In some cases I have used the bag and in 
others operated without it. I believe that 
we can get along just as well without as 
with it. Where we want to operate on 
the prostate, I think we can be better aided 
by an assistant introducing his finger into 
the rectum and pushing the prostate up- 
ward and forward, than with the bag. I 
have never found it necessary to tie any 
vessels in the bladder wound. As soon as 
the bladder is emptied, distension of the 
vessels will disappear and the hemorrhage 
will cease. 1 reported, I think to this 
Society, some time ago a very interesting 
case, a patient of Dr. Palmer's, where I 
operated for tumor of the bladder by the 



134 



Society Reports. 



Vol. lxviii 



supra-pubic method. The tumor in this 
case obstructed the flow of urine through 
the urethra; after closure of the supra- 
pubic wound the man was able to pass 
water by the urethra, throwing it three 
feet from him. This is not the usual re- 
sult in such cases. As a rule they do not 
recover the power of completely emptying 
the bladder through the urethra. 

De. E. E. Palmer: I am forced to be- 
lieve that the modern operation of supra- 
pubic cystotomy will eventually find its 
proper place to be where it has been fully 
determined that the old-fashioned opera- 
tion through the perineum is not admis- 
sible. 

With reference to the case just spoken 
of by Dr. Koberts, I believe that probably 
the perineal operation with curetting 
would have relieved the man with less after 
trouble. I believe that in the majority of 
cases where operations of this sort are 
done on the bladder, the tone of the blad- 
der is so permanently destroyed that we 
cannot expect to restore the normal action 
of this organ through the natural passages. 
In the case Dr. Eoberts has spoken of 
the result was all that could be desired, 
but I was impressed in that case, as I have 
been in a number of others I have wit- 
nessed, that if any man thinks it is a com- 
paratively simple operation to go into the 
bladder above the pubes, he is the worst 
fooled man that ever took a knife in his 
hand. It has impressed me as being one 
of the most tedious, difficult and deceiving 
operations that a man can attempt. For 
my own part I do not expect to do, in my 
particular line of work, a great deal of this 
form of surgery ; but, when I do it, my own 
preference is to go into the bladder where 
it is possible, through the perineum. I 
have no doubt that men with larger ex- 
perience and with greater statistics to back 
them up than I am possessed of, are anx- 
ious, ready and hopeful in the matter of 
preference of supra-pubic cystotomy, not- 
withstanding the almost certainty of more 
or less permanent fistula which is one of 
the serious objections to the operation. I 
would always exclude the feasibility of op- 
eration through the perineum before re- 
sorting to supra-pubic cystotomy. 

Dr. W. C. Dugan : I have enjoyed the 
paper and consider it a most excellent one 
in the main, but I cannot refrain from 
taking issue with Dr. Chenoweth in refer- 
ence to the use of the rectal bag, also the 



use of .water in distending the bladder. In 
the first place I do not believe that the 
rectal bag is of any service whatsoever in 
supra-pubic cystotomy, and that if the rec- 
tal bag is indicated at all, it is after the 
bladder has been opened. It might be 
well enough to insert the bag if you are 
operating on the prostate ; or on the base 
of the bladder; or for tumors where you 
want to bring the prostate up as high as 
possible. There is always danger of rup- 
turing the bladder and rectum by disten- 
sion and pressure from use of the rectal bag. 
I think it has been demonstrated beyond a 
doubt that we cannot elevate the fold of 
the peritoneum by distending the rectum 
with the rectal bag. You simply push the 
prostate and bladder up toward the sym- 
phisis. I do not believe the bladder 
should be distended until after we expose 
the prevesical fat ; it being easier in my 
opinion to cut down upon an empty bladder 
rather than upon a full one. After you have 
made your incision, exposing the prevesi- 
cal fat, have your syringe ready and let 
the assistant fill the bladder with fluid and 
you can feel the fold of the peritoneum 
slip under the finger. When this sensation 
is felt, then have the catheter tied around 
the penis and the bladder opened. 

While supra-pubic cystotomy is attended 
with considerable danger I do not 
think the mortality should be over five per 
cent, in young, healthy subjects. In old 
men and in patients with chronic disease 
of the genito-urinary passages, it must 
necessarily be higher. 

I think the doctor's precaution of sutur- 
ing the bladder to the abdominal wall by 
a silk ligature is an admirable one and 
should not be overlooked. Suturing the 
bladder is a very important matter if we 
use silk. It is difficult to get the edges so 
accurately brought together that the ends 
of the suture will not fall through. I op- 
erated upon a patient some time ago and 
had this misfortune to follow. A piece of 
the suture material dropped into the blad- 
der through the incision, around which a 
calculus formed requiring a second opera- 
tion. 

In regard to drainage: I believe in 
these cases there is nothing equal to iodo- 
form gauze. I think it is better than a 
tube and gives the patient much less pain. 
It is necessary to be very careful to have 
your gauze well protected and all the little 
threads removed, wrapped with silk so 



January 28, 1893. Society Reports. 



135 



as to be doubly sure that you are not 
going to leave in any of the threads to 
cause the formation of calculi. I do not 
think the operation of supra-pubic cysto- 
tomy advisable in impermeable stricture of 
the urethra; I have yet to see a case that 
could not be relieved by simple operation 
either by external urethrotomy without a 
guide, or by the perineal method. I agree 
with Dr. Palmer that supra-pubic cysto- 
tomy is an operation of considerable mag- 
nitude, and was somewhat surprised to 
hear Dr. Hunter McGuire state, at the 
meeting of the Southern Surgical and 
Gynecological Society, that the operation 
was as simple as the opening of a boil ; I 
am sure he made a mistake in that. At 
any rate it does not appear so to me. It 
is an operation which requires an accurate 
anatomical knowledge and perfect surgical 
technique. 

Dr. W. L. Kodman: I am very much 
disposed to accept the steps of supra-pubic 
cystotomy as given by Dr. Ohenoweth as 
being the proper ones. I believe that in 
the majority of cases it is better to use the 
rectal bag. It has been demonstrated that 
you lift the peritoneum and bladder higher 
by use of the bag than you can possibly do 
without it. I believe that the danger in 
using the rectal bag has been over estimated. 
It seems to me that it is a very weak bladder 
that is going to be ruptured by use of the 
rectal bag. I have always used the bag 
and shall continue to do so in every in- 
stance. Instead of ligatures I use two 
tenacula to bring the bladder well into 
view, and think this is the ideal way of 
lifting the bladder up into the abdominal 
wound. I do not like the use of ligatures 
for this purpose; they tear out and do 
more damage to the bladder wall than do 
tenacula properly used. Their introduc- 
tion is also more tedious. I agree with 
Dr. Eoberts in regard to hemorrhage; it 
nearly always ceases as soon as you have 
opened the bladder. 

I further agree with the essayist in the 
position taken concerning supra-pubic cys- 
totomy for so-called impermeable stricture. 
It occurs to me that supra-pubic cystotomy, 
while not an easy operation by any means, 
is both easier and safer than perineal sec- 
tion without a guide. I have a case now 
that I propose to do a supra-pubic cysto- 
tomy on next Wednesday or Thursday. 
It is a case of impermeable stricture that I 
have tried to enter twice and, rather than 



do a perineal section without a guide, I 
shall perform supra-pubic cystotomy. I 
am very frank to say, however, that I have 
never in my life failed to get into the 
bladder through the urethra when the 
patient was put under chloroform. After 
putting the patient just mentioned under 
the influence of chloroform, if I fail to 
enter the bladder through the urethra, 
then the supra-pubic operation will be 
resorted to. 

Dr. H. H. Grant: I was very much 
surprised to hear Dr. Dugan begin his dis- 
cussion by stating that supra-pubic cystot- 
omy was so simple as to be readily done 
without the use of any artificial means to 
raise the bladder up; afterward to state 
that the mortality was only five per cent, 
and then to criticise Dr. Hunter McGuire 
for teaching medical students concerning 
an operation as serious and grave as this 
one is. I think it is a very serious matter 
for surgeons of reputation and ability to 
educate young men to believe that any 
surgical operation can be done without 
great danger, or without considerable skill 
at the best to avoid this danger ; that every 
means possible to make it easier and safer 
should be employed : and that no methods, 
which have received the approval and sup- 
port of experienced and competent sur- 
geons, should be discarded or condemned 
without some definite reason therefor. 

I am firmly persuaded that in all opera- 
tions of supra-pubic cystotomy that I have 
witnessed, and there have been quite a 
number, without the bag the peritoneum 
has appeared in the wound. I am also con- 
vinced that it is rarely seen where these 
means are employed. 

A little difference is always to be found 
in the resistance of the tissues of the 
live and the dead body. The majority of ex- 
periments which have been employed to 
determine how far the peritoneum could 
be pushed up have been upon the dead 
body. Ability to push up the peritoneum 
and bladder by artificial means experience 
has shown to be very considerable, and, in 
many cases, the peritoneum has been found 
to be pushed three inches above the pubis 
— so far that there is no possibility of injur- 
ing it in the first incision — and easily 
pressed out of the way by the finger with- 
out any fear of wounding it. Certainly 
no danger can be experienced in distending 
the rectum with eight ounces of fluid in a 
rubber bag. When the plane which sup- 



136 



Society Reports. 



Vol. lxviii 



ports the prostate and the rectal base of 
the bladder has been raised toward the 
level of the pubic arch by distension of 
the rectum, the peritoneum will be pro- 
portionately higher as a matter of simple 
mechanics, and when the bladder is after- 
ward filled with the solution the fold of 
peritoneum rises much more readily. 

Dr. W. C. Dugan: Eight at this point 
I would like to ask the speaker if he be- 
lieves that eight ounces of fluid in a rub- 
ber bag will lift the bladder up three 
inches? 

Dr. H. H. Grant: I have already 
stated that in all the operations I have 
seen, and there have been more than a 
dozen of them, in which the rectal bag- 
was used, the peritoneum did not appear 
in the wound. If the peritoneum is not 
pushed up three inches, it is certainly 
pushed up some. And with this precaution 
the peritoneum has not appeared in the 
wound where the rectal bag was properly 
distended and the bladder was distended 
afterward. Upon the dead subject I have 
done this operation over one hundred 
times, and occasionally the peritoneum 
would be encountered. In a few 
instances it dropped down quite upon 
the pubis; but in these cases it was 
not pushed up either by distension 
of the bladder or distension of the rectum. 

Of course in my remarks I simply refer 
to my experience, and my observation is 
coroborative of the wisdom of taking all 
means to prevent any possible wounding 
of the peritoneum, which is almost cer- 
tainly a fatal accident unless the peri- 
toneum be promptly closed up without 
any chance of infection. I look upon the 
operation, proper care being taken, as one 
comparatively easy to do. I look upon it 
as even less attended by risk than the 
operation which Dr. Palmer prefers, so 
far as the operation itself is concerned. 

With respect to the hemorrhage which 
occurs after this operation, so far as the 
simple operation is concerned, I agree 
with Dr. Roberts that it is rarely trouble- 
some. In operations upon the bladder for 
the removal of tumors, and especially in 
prostatic troubles, the danger of hemor- 
rhage is very considerable, and it has been 
the practice of some to cauterize the 
bladder with the hot iron or thermo- cautery 
A safer step is to tampon the bladder with 
gauze fixed by a thread drawn out through a 
perineal wound or through the urethra as 



suggested by Keyes. There are a number 
of points with respect to the management 
of this operation presented in the paper 
that meet my approval thoroughly. It 
should be the object of every surgeon to 
avoid injury to the peritoneum in opera- 
tions of this character, and I believe we 
ought to employ every possible means in 
order to prevent injury. The details of 
the technique which Dr. Ohenoweth has 
given us are both interesting and adequate ; 
are much upon the original modifications 
by Petersen and, having stood the test of 
time, are to be relied on. 

Dr. W. 0. Dugan: I am a little sur- 
prised at the position taken by Dr. Grant 
in reference to my former remarks. I did 
not mean to criticise Dr. Hunter McGuire, 
except in as far as his statement that 
" supra-pubic cystotomy is as simple as 
opening a boil." I agree with Dr. Palmer 
that it was an operation of considerable 
magnitude. Now the point I wished to 
make was, the best means of avoiding the 
dangers in this operation were by taking 
the precautions which I have mentioned, 
i. e., not to distend the bladder until you 
expose the prevesical fat, and then in order 
to locate the peritoneum after the bladder is 
exposed. If you will follow the precaution 
now being practiced by the best surgeons 
in America and Europe, there will be no 
danger of wounding the peritoneum; that 
is, to first distend the bladder, then slip 
your fingers well down toward the neck, 
lifting the bladder up into the palm of 
your hand until you feel the fold of the 
peritoneum slip above, then the bladder 
can be incised without danger. 

One other point: I am greatly surprised 
to hear Dr. Grant state that he can lift 
the peritoneum three inches by an eight 
ounce rectal bag. I think experiments 
have proven pretty clearly that the bladder 
can be distended with water and after- 
ward distend the rectum and it simply 
forces the prostate forward but does not 
perceptibly increase the space between the 
fold of the peritoneum and the symphisis. 

Dr. A. M. Oartledge: It has been 
my observation that whenever a new oper- 
ation comes up in surgery everybody is 
writing upon its technique, etc. After a 
while it dies down, and all the time it is be- 
ing subjected to the crucial tests of experi- 
ence and practice. After a year or two 
you will find some of the most interesting 
points concerning it have never been 



January 28, 1893. Society Reports. 



137 



brought up. I think this is notably the 
case with supra-pubic cystotomy. It was 
largely written upon a year or two ago, but 
I have hardly seen it mentioned within the 
last eighteen months. I perfectly agree 
with almost everything Dr. Chenoweth 
has said in reference to the operation. I 
have myself paid considerable attention to 
the matter, have done several operations, 
and witnessed others. I do not quite 
agree with the essayist with reference to 
the use of the rectal bag. I believe, like 
Dr. Dugan, that the rectal bag cannot 
raise the peritoneal fold proper more than 
one-quarter of an inch. If this were the 
case there would be danger of rupture. 
I have never used the bag as I never con- 
sidered it of any service. Further, the 
rectum is the seat of a plentiful nerve 
distribution. I think it was proven 
several years ago that often very alarm- 
ing syncope resulted from simple dis- 
tension of the rectum by the speculum, 
and I see no reason why anything that 
would distend the rectum might not pro- 
duce the same result. I think it would 
probably be the most dangerous part of 
the operation to tightly distend the rec- 
tum, even with a soft rubber bag. 

I believe that a free incision should be 
made over the bladder, the prevesical 
fat and peritoneum can be peeled up from 
the bladder with the fingers until every- 
thing is out of the way, then the necessary 
incision can be made in the bladder for re- 
moving any growth or stone that may be 
found. I think the supra-pubic operation 
preferable to the perineal method for im- 
permeable stricture ; in fact, in my opin- 
ion the perineal operation without a guide 
is a most dangerous procedure, and useful 
only as a life-saving measure in the cases of 
larged prostate of the old. 

Dr. Jas. S. Chenoweth: I use Pe- 
tersen's bag in these operations because I 
believe better results can be obtained with 
it than with any other. I recommend the 
use of the rectal bag to raise the perito- 
neum, but more especially to raise and 
steady the base of the bladder which 
greatly facilitates operation on this organ. 

I am sorry there was no more discussion 
upon the question of drainage, and 
whether the bladder should be fastened to 
the abdominal wall or dropped back into 
the pelvis. In most of the operations I 
have seen, the custom has been to simply 
open the bladder, remove the stone or 



growth, and then allow the viscus to drop 
back into the cavity of the pelvis. This 
necessitates the use of a tube for drainage, 
which is liable to leave a small discharg- 
ing sinus after the operation; especially 
is this the case when the operation is done 
for cystitis from enlarged prostate, where 
the obstruction at the bladder neck can- 
not be thoroughly removed. 



Preventive and Curative Drinks and Medi= 
cines. 

Put not your trust in nostrums ; cholera 
does not " come by Providence and go by 
medicine," although that is a common and 
ignorant belief in respect to it, and many 
other diseases. A tried and safe preven- 
tive of the tendency to diarrhoea (which 
should always be checked) is sulphuric 
acid lemonade, made by acidulating boiled 
and sweetened water to taste with dilute 
sulphuric acid (or, as at the post-office, 
Dr. Waller Lewis's very palatable sul- 
phuric orangeade. ) The citric acid lemon- 
ade lately vaunted was rather inferior in 
value to this. The cholera bacillus, as we 
now know, was favored by an alkaline 
fluid, and did not live in acid media. An 
excellent and well tried preventive of the 
prevalent slight diarrhoea was the Vienna 
mixture (used in barrels formerly in hos- 
pital practice.) It consisted essentially of 
fifteen drops of dilute sulphuric acid to 
six ounces of boiled and sweetened water, 
to which might be added, under medical 
advice, ten drops of sulphuric ether and 
five drops of laudanum for an adult. On 
ice-bags, camphor solutions, and other ex- 
pedients of the kind no reliance could be 
placed, except in skilled hands and for se- 
lected cases. Many people poisoned them- 
selves with camphor during a late epi- 
demie, as a precaution against cholera. 
Once established, and in well-marked cases 
of Asiatic cholera, drugs would do little to 
cure. The mortality of cholera all over 
the world and in all epidemics had defied 
drugs — just as severe arsenical poisoning 
would do — and varied according to inten- 
sity and the age and condition of the 
patient from forty-five to sixty-four per 
cent. It was eminently a case in which 
prevention was far more efficacious than 
cure. — Ernest Hart. 



Manager. " What's the row ?" 
Assistant. "The two-headed boy is 
quarrelling over a piece of pie." 



138 



Correspondence. 
CORRESPONDENCE. 



Vol. lxviii 



NEW YOEK LETTER.* 



At a recent meeting of the Practitioners 
Society of New York, held at the Academy 
of Medicine, a discussion took place be- 
tween the prominent physicians present on 
the question of food in continued fevers. 
The question was of importance as it is the 
general belief among the profession that 
solid food should not be given, particularly 
in typhoid fever. 

Dr. A. H. Smith said that he believed 
he had often prolonged cases of typhoid by 
restricting his patient to a milk diet, and 
that he had often noticed a decided im- 
provement as soon as solid foods were 
given. He thought that fermenting and 
irritating drinks, so frequently given, had 
a more deleterious effect upon the ulcerated 
patches than had solid food; that solids 
were not in a condition upon reaching the 
ileum to irritate a typhoid ulcer, and that 
milk dilutes digestive fluids and renders 
them inferior as solvents. 

Dr. J. W. Roosevelt said that a pro- 
longed milk diet prolonged a fever. He 
mentioned cases in which the cessation of 
a milk diet, and the giving of stale bread 
and finely chopped meat, gave marked 
good results ; a patient on a fluid diet is 
hungry, and hunger is pain; the giving of 
solids, and consequent relief of this pain, 
lowers the temperature which is kept up 
by the pain. Professor Beverly Robinson 
brought up the point that milk curdles in 
the stomach, hence part of it becomes 
solid; and this solid is more apt to irritate 
typhoid ulcers than would such foods as 
bouillon, beaten egg, and wine jelly, as 
they are not solid upon reaching the ul- 
cers. 

Dr. Robert Abbe feeds his typhoid pa- 
tients peptonized milk, junket, scraped 
meat, baked potatoes and stale bread. 
He said that none of these were any more 
solid upon reaching the seat of the ulcers 
than would be milk. 

Dr. W. H. Polk said that a few years 
ago it was the custom to keep laparotomy 
patients upon an exclusive milk diet for 
two days before and for ten days after the 
operation, and that many fatal cases, at- 

* Special Correspondent to The Medical and 
Surgical Reporter. 



tributed to sepsis and shock, were due to 
inaction. He has noticed a decided fall- 
ing off in the death-rate since this custom 
has been abandoned. 

★ ★ ★ 

At a recent clinical lecture in Bellevue 
Hospital, Professor H. M. Biggs strongly 
contradicted the teachings of most path- 
ologists regarding the etiology of diabetes 
mellitus. He said that the malady was in 
no way due to any diseased condition of 
the liver; that a pathological liver may 
cause glycosuria, but that this was in no way 
related to diabetes mellitis. He gave as 
it's cause a brain lesion from traumatism, 
or mental anxiety, grief, sudden fright, or 
mental shock of any kind. He said that 
heredity was a prominent predisposing 
cause, and that he has often noticed 
several cases among members of the same 
family. 

★ ★ ★ 

Professor W. T. Lusk performed sym- 
physiotomy on a patient at the Emergency 
Hospital a few days ago. The woman had 
been in labor thirty hours when brought 
to the hospital. An attempt had been 
made by an outside physician to deliver 
the child with forceps, which resulted in 
severe lacerations of the vagina and cer- 
vix. The degree of pelvic contraction was 
such as to forbid any attempt to deliver 
the child without the operation. As the 
condition of the mother would not permit 
of the severe mutilation necessitated by 
Caesarian section, the choice lay between 
craniotomy and symphysiotomy. The lat- 
ter was chosen as it presented the advan- 
tage of the delivery of a living child and 
involved the mother in less risk from 
sepsis. After the pubes were shaved and 
rendered aseptic, an incision was made 
through the mons veneris and the sympyh- 
sis divided from below upward. Assis- 
tants held the sides of the pelvis, not al- 
lowing a separation of the pubic bones of 
more than an inch, thus avoiding damage 
of the sacro-iliac synchondrosis and the pel- 
vic viscera. The child was then delivered 
by the forceps. The pubes were brought to- 
gether and held in place by sutures 
through the soft parts and a tight bandage 



January 28, 1893. Correspondence. 



139 



around the pelvis. At the present writing 
the child is doing well and the mother 
is living. But the length of time she was 
in labor, the severe lacerations she received 
before admission and her critical condition 
when an operation was decided upon, give 
her but slight chance for recovery. 
★ ★ ★ 

Dr. L. A. Sayre, in a recent lecture, 
stated that he had exsected seventy-three 
hip joints. The operation is done much 
less frequently than a few years ago, as 
modern physicians are able to diagnose 
and properly treat hip-joint disease in its 
incipient stage. The venerable professor 
exhibited at the lecture a dozen patients 
on whom he had performed the operation. 
Most of them walked without any incon- 
venience and without the use of a cane or 
crutch ; call were able to run up and down 
stairs and to do their work as well as any. 
A patient on whom he operated several 
years ago and removed the head of the 
femur and upper three inches of the shaft, 
recently won a prize in a skating contest 
held in Central Park. He said that the 
good results were due to the care he 
exercised in the preservation of the peri- 
osteum from which new bone developed 
and replaced the removed tissue. 

Although the present epidemic of 
typhus fever is on the decline, new cases 
and deaths are reported every day. At 
present there are about thirty-five infected 
buildings in the city, many of which are 
cheap lodging houses. Cases when dis- 
covered are at once transferred to Bellevue 
Hospital, where they are kept out-of-doors 
in carefully constructed and well heated 
tents until their removal to North 
Brothers Island. The tent plan not only 
lessens the liability of the extension of 
the infection to the hospital patients, but 
is a sanitary measure proven to yield good 
results in any specific fever. There is no 
danger of the patient catching cold if he 
is not subjected to a draught ; his tempera- 
ture is lowered, and the poison is diluted as 
it cannot be in a hospital-ward or sick-room. 
The treatment has been to reduce the tem- 
perature, relieve restlessness, make the 
patient comfortable and promote nutrition. 
The death-rate has been about twenty-five 
per cent. 



Cantani claims that no other agent 
equals tannic acid in the treatment of 
cholera. 



Treatment of Compound Fracture. 

A writer in the Boston Medical and 
SurgicalJournal says that the treatment 
of compound fractures, during the past 
few years, has undergone radical changes 
and marked improvement, which has been 
brought about by two causes: (1) Thor- 
ough exploration and cleansing of the 
wound and antisepsis. (2) By the recog- 
nition of the importance of the physiologi- 
cal principle of complete rest to a frac- 
tured bone. The results from older 
methods in Guy's Hospital in the twenty 
years from 1841 to 1861, was a mortality 
of 28 per cent. ; in the New York Hospital 
during a similar period there was a mor- 
tality of 48 per cent. ; in the Obuchow 
Hospital Report of St. Petersburg there 
was a mortality of 68 per cent. Under 
modern methods Dennis reports 681 cases 
of compound fracture with one death from 
sepsis, giving a death rate of one-seventh 
of one per cent. The important points to 
be observed are : (1) That every compound 
fracture of the thigh, leg, arm or fore- 
arm, should be rendered scrupulously sur- 
gically clean and should be absolutely 
immobilized. (2) That this immobiliza- 
tion is conveniently obtained by the light, 
circular plaster of Paris washed bandage. 
(3) That a plaster of Paris bandage should 
be allowed to remain on a limb over a fort- 
night in the first month of treatment of a 
compound fracture, as backward bowing 
and lateral displacement can be avoided by 
this precaution. (4) That while pus, 
slough, necrosis or deformity may excep- 
tionally occur, yet the rule is, union by 
first, intention, and the early restoration of 
limbs to usefulness. 



Treatment of Ringworm. 

Crawford Warren, F. R. C. S. I., in 
the London Lancet, suggests the following 
treatment for this troublesome affection: 

The affected region should first be 
washed with soap and warm water con- 
taining a little carbonate of soda and then 
well dried. Acetic acid should then be 
thoroughly applied with a small brush, 
and in the lapse of about five minutes, 
when the acid will have soaked into the part, 
an ointment composed of sixty grains of 
chrysophanic acid to an ounce of lanoline 
should be rubbed in. This treatment 
should be carried out daily for such a 
period as may be necessary. — Prac. Mon. 



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Saturday, January 28th, 1893. 



EDITORIAL. 



, ABDOMINAL SURGERY— ITS REVOLUTION. 



In the Indiana Medical Journal for De- 
cember there appeared an article by an emi- 
nent western surgeon entitled " Abdomi- 
nal Surgery — Its Evolution and Involu- 
tion." 

This article is remarkable more for what 
it insinuates than for what it says. 
While it is strong in many respects and 
offers plenty of food for thought, its 
animus seems to be a desire to smirch the 
private character of Lawson Tait and to 
belittle his work. It is an effort to create 
the impression that he and men who like 
him publish a low mortality in their ab- 
dominal work are, if not downright liars, 
at least remarkable for handling the truth 
with a great deal of economy. 

Mr Tait's work and character have so 
long been open to the inspection and 
scrutiny of the whole medical world, his 
reports have been so often verified, and his 
results duplicated by Ms pupils and others 
in this country that any attempt at the 
hands of an American operator to belittle 
him is likely to create suspicion that some- 
body has a grievance. 



When an operator demands that here- 
after all who publish low mortalities shall 
be compelled to furnish affidavits and cer- 
tificates that their statistics are true, it 
begins to look as though he might be 
measuring others by standards applicable to 
himself. Such a method of reasoning is a 
very fallacious one indeed. The fact 
that those men who publish results in ab- 
dominal work with a mortality as low as 
three per cent, invite the closest inspection 
of their work and have their operating 
rooms daily crowded with visiting physi- 
cians from all parts of the country, is a 
complete refutation of any insinuation 
that tin-horn blowing constitutes the chief 
element in their success and that falsehood 
predominates in what they publish. There 
are too many honest, earnest and closely 
scru fcinizing physicians visiting and study- 
ing these men, who write up what they see, 
and that only from a laudable desire to 
spread the truth for the benefit of others 
who seek information; and who expect 
their patients to profit by what they gain 
in knowledge — there are too many jealoua 



January 28, 1893. 



Editorial. 



141 



observers for accusations like those which 
permeate the article under consideration, 
to prove other than boomerangs to the 
accuser. 

If the surgeon who wrote this article 
will spend a little more of his next vaca- 
tion in Philadelphia and less in Vienna, 
he can have an opportunity to see just 
such work as that described by a number 
of men whom he dubs sycophants. Then, 
if he be the well-spring of truth his article 
would lead us to infer he claims to be, he 
can go home, and if he publishes anything 
of what he sees, it will be couched in a far 
different spirit than that revealed by the 
evolution and involution of his late effort. 
He will at least be enabled to recognize the 
truth when it confronts him in the King's 
Highway. 

It was Lawson Tait who revolutionized 



the surgery of the abdomen, and who 
taught us that it was not the going into 
the peritoneal cavity that produced dis- 
aster so much as the manner in which it 
was done and what one took in with him. 
His saying that he would as soon put his 
finger into the peritoneal cavity as into 
his pocket was no idle boast, but came from 
an honest conviction born of an experience 
in more than three thousand sections. 

Whenever another man has added to 
modern surgery as many things as Tait, 
and has taught the surgical world as much ; 
whenever one arises to whom suffering 
woman owes so much; then, and not till 
then, may he brand Tait a liar, if he be will- 
ing to confess ignorance as extensive and 
principle as unstable as the three thousand 
miles of water between him and the 
traduced. 



"HOUSE" QUARANTINE. 



Last week we noted the passage . by the 
United States Senate of a National quar- 
antine measure, which poor as it was, 
seemed to offer some hope of protection 
against foreign invasion by armies of 
cholera microbes. This measure, crippled 
as it was by passing through the mill of 
practical politics, was sent to the House. 
Whence, after the skillful and patriotic 
treatment at the hands of Tammany sci- 
entists in consultation with experts from 
Florida, Louisiana and Texas, it emerges 
totally emasculated. The bill as sent 
from the Senate was amended in the House 
to prevent it in any way restricting, relax- 
ing, modifying or suspending State or 
municipal quarantine regulations. The 
elimination of this objectionable feature 
was accomplished by citizen Bourke 
Cochran, of Tammany (formerly called 
New York State), who discovered in it 
the thinly disguised intention to make the 
Federal authority superior to that pos- 
sessed by the appointee of his liege mas- 



ter, His Majesty, the Dictator of Tam- 
many Hall. 

As suggested by a Representative from 
another State, the title should be amended 
so as to read " A bill authorizing the 
States to declare quarantine against 
the United States." This measure should 
become a law immediately, so as to 
permit the Burgess of any little town 
on the sea coast, or on a State line, 
to defy Federal regulations, and enforce 
its own effective municipal laws. 

It is curious to note how the same ob- 
ject appears viewed from opposite sides. 
The legend tells us of the two knights 
who engaged in mortal combat over the 
composition of the shield, of which each 
had seen only one side. In this 
part of the country there is a growing 
belief that the opposition to a Federal 
Quarantine was largely aided and abetted 
by an alleged steamship and railroad com- 
bination, whose interests it would seem to 
have antagonized. From the point of view 



142 



Translations. 



Vol. lxviii 



of a Texas medical contemporary of un- 
doubted honesty and ability, the bill ap- 
pears to be supported by this same al- 
leged lobby of steamship and railroad com- 
panies in their own interests. Thus it is 
that whether in support of, or opposed to 
this measure, the steamship and rail- 
road companies are very considerable fac- 
tors in the question. This bill will now 
go back to the Senate, and if it is received 
as an original House bill (and it surely is 



original enough), it may be amended suffi- 
ciently to make its meaning diametrically 
different, and then be considered by a con- 
ference committee. The results of this 
last combination will be awaited with cur- 
iosity by the Profession which, in event of 
an epidemic, will bear the heaviest portion 
of the wearisome burden, and will be made 
the popular scape goat for the sins of 
omission and commission of the Represen- 
tatives of the people. 



TRANSLATIONS. 



RUPTURE OF THE UTERUS.* 



H. Fehling, (Klin. Vortr. N. F., No. 
54.) 

The author presents the history of a 
case as the foundation of his dissertation 
on this subject. 

The case a II — para of thirty-six years, 
having a contracted pelvis (Conju- 
gata vera 7.5-7.7). The first child had 
been small and was born spontaneously. 
The author saw the patient first during 
her second labor after a spontaneous rup- 
ture of the uturus had taken place in the 
anterior and lower portion of the uterine 
wall. Delivery was at once performed by 
perforation and dilatation, and the treat- 
ment consisted of passing a tampon of 
iodoform gauze through the vagina into 
the uterine opening. The size of the tear, 
its possible septic condition due to the 
blood and meconium, the persistent hemor- 
rhage all induced the author to resort to 
abdominal section in order to unite the 
tears in the uterus. Careful investigation 
disclosed a second tear in the uterus ; both 
were closed by several rows of sutures; 
drainage and recovery. In connection 
with this case F. considers the causes of 
uterine rupture, its symptoms and treat- 
ment. 

In threatening rupture of the uterus 
he advises the use of chloroform and mor- 
phia as a means to reduce the too active 
contractions of the uterus and if possible 
to terminate labor by forceps or perfora- 
tion. In transverse positions the obste- 
trician will find it necessary to first attempt, 

* Translated for The Medical and Surgical 
Reporter, by Marie B. Werner, M, D. 



under complete anesthesia, careful version. 
If tetanic contractions of the uterus re- 
main unabated, decapitation is indicated. 
If the rupture has taken place, prompt 
and careful delivery is indicated in which 
perforation or cephalothrypsia may be- 
come necessary. It is rarely possible to 
extract the foetus by its feet through the 
tear. Version is in all cases of existing 
rupture contra-indicated. If the child 
has escaped entire or partially through the 
tear into the abdominal cavity, the only 
proper procedure is laporotomy in order 
to deliver the child and at the same time 
repair the injuries to the uterus. If the 
tears are extensive or if they should be 
circular, partially separating the uterus 
from the cervix, Porro's operation is in- 
dicated. 

The question which is presented at the 
present time, namely, should laparotomy 
be the first step in the treatment of rup- 
ture of the uterus, even though the child 
has been extracted per vias naturales, is 
answered by the author in the affirmative, 
provided the condition of the patient will 
permit so grave a procedure. 

If section is decided upon, the author's 
mode of procedure is as follows: After 
opening the abdominal cavity, it is first 
cleansed of the blood and amniotic fluid, 
etc., by means of the physiological solu- 
tion of salt. The uterus is then raised, 
the wound disinfected, and an iodoformized 
strip of gauze passed through the wound 
and allowed to extend out through the 
vagina. The wound is now closed with 
three rows of sutures, respectively uniting 



January 28, 1893. Translations. 



143 



the decidual, muscular, and serous layers; 
if necessary, some superficial stitches are 
added ; after again cleansing the abdominal 
cavity thoroughly the abdominal wound is 
closed. The iodoform gauze is removed 
from the vagina after twenty-four hours. 

In cases where incomplete rupture has 
taken place, where the peritoneal covering 
is intact the iodoform gauze tampon into the 
uterus is advocated by the author, a pro- 
cedure which the author preferred to the 



use of a rubber drain. The gauze in these 
cases is not removed until from the sixth 
to the tenth day. 

Formerly more than three-fourths of the 
patients died as a result from this injury. 

F. believes that careful suturing of the 
uterine wound will improve the prognosis 
in these cases, the same as that of Cesar- 
ean section, since Sanger's method of su- 
turing of the uterus has become recog- 
nized and practical. 



CONTRIBUTION'S TO THE PATHOLOGY AND SURGICAL THERAPY OF 
CHRONIC DISEASES OF THF CCECUM.* 



F. Salzer (Archiv. ofKlinische Chirurg., 
XLIII page 101). The material used in 
this study has been taken from Billroth's 
clinic and covers a space of ten years. 
During this time there were twenty-five 
operations on twenty-three patients for 
chronic inflammations of the coecum. A 
fistula resulting in one of the cases neces- 
sitated a second operation. The other 
case was a resection of the intestine for 
carcinoma. A return of this disease made 
it necessary to perform Ileocolostomy. 

Among the twenty-three patients, fif- 
teen were males and eight females. 

Ten were resections for carcinoma (eight 
males and two females). There were four 
recoveries (two males, and two females). 
Five operations were for tuberculous 
ulcerations and stenoses of the intestines 
at the coecum — (five males, one female). 
Of these there were four recoveries (three 
males, one female). Eight operations for 
fecal fistula (three males, five females). 
Of the five females, three recovered. 
Two males recovered from the operation, 
one of which however required a second 
operation owing to the presence of a fecal 
fistula. The third male required a resec- 
tion of the colon which ended fatally. 
The mortality of non-malignant tumors 
was twenty per cent. That of malignant 
tumors sixty per cent. That of fecal 
fistuLae 57.5 per cent. The mortality was 
higher among men (50 per cent.) because 
they were seen too late, while that of the 
women was 22.2 per cent. Alarming in- 
testinal symptoms existed in three cases at 
the time of operation. The difficulty in 

* Translated for The Medical and Surgical Repor- 
ter, by Marie B. Werner, M. D. 



diagnosing between tubercular and car- 
cinomatous growths in the appendix is 
very great, the microscopical investiga- 
tions being the only reliable means. Of 
the operations there were four intestinal 
sutures including one lateral suture ; eigh- 
teen intestinal resections, and three intes- 
tinal anastomoses. In regard to the resec- 
tion of the intestines the author believes 
that the simple transverse section of intes- 
tines with a circular suture can be 
recommended also for the resection of the 
coecum, with this exception, that owing to 
the difference in the lumen of the cut ends 
of the intestines at this location one would 
have to be cut a little diagonally. If the 
tumor has become fixed by the fistulas and 
perityphlitic abscesses the mode of opera- 
ting as well as the prognosis becomes 
changed. Of the whole of the eight 
fecal fistulae only one was thoroughly cured, 
four returned and three died, while of the 
seventeen other cases ten were cured and 
seven died. The author does not approve 
of intraperitoneal tampons or drainage. 



Traveler. — "Do you think the lynch 
law you have here decreases the number 
of murders ? " 

Native. — "Wall, I dunno; but it de- 
creases the number of murderers. " 

"If you don't stop smoking iu office 
hours, you'll get fired, that's all," said 
Wagg to his bookkeeper. 

" Is that quite just to one who does his 
work faithfully ? " asked the scribe. 

" Certainly. Where there is so much 
smoke, there must be fire." 



1U 



Translations. 



Vol. lxviii 



Ischio=Pubeotomy, or the Operation of 
Farabeuf.* 

This new obstetric operation is described 
by Pinard in a communication to the 
Academy of Medicine of Paris. He em- 
ployed it in the case of a woman thirty-two 
years of age, who presented herself to him 
with an oblique pelvis associated with an 
ankylosis of the left sacro-iliac articulation. 
Her first pregnancy had been terminated 
by means of basiotripsy; the second by 
premature labor at the eighth month; the 
third was an instrumental labor resulting 
in the death of the fetus, and almost that 
of the mother; the fourth was terminated 
by premature delivery of a dead child; 
and finally she came in November, 1892, 
again pregnant and expressing the wish 
to be delivered of a living child. At first 
it was decided to perform symphyseotomy, 
but the existence of the sacro-iliac ankylo- 
sis led to the belief that the gain following 
the operation would probably be insuffi- 
cient, and it would be impossible by it to 
sensibly increase the dimensions of the 
antero-posterior diameter, which was re- 
duced to eight centimeters and a-half. 
Csesarean section appearing to offer 
but slight chances for the mother's recov- 
ery, the operation of ischio-pubeotomy was 
decided upon. According to Farabeuf, 
the originator of the method, this opera- 
tion will permit of the passage of a head 
much larger than the normal, nearly a 
sixth larger. The technique was as fol- 
lows : Labor having lasted fourteen hours 
the ichio-pubic ramus was divided and 
then the horizontal branch of the pubis on 
the ankylosed side five centimeters from 
the median line. The Tarnier forceps 
were then applied at the superior strait 
and with scarcely any traction a living in- 
fant weighing 3,970 grammes was deliv- 
ered. During the traction upon the for- 
ceps there was a spontaneous separation of 
the two severed segments of 2.6 centi- 
meters, and, at a given moment, of four 
centimeters. 

The sole difficulty of the operation con- 
sists in passing the chain-saw with which 
to cut the horizontal branch of the pubis. 
With a suitable needle this difficulty dis- 
appears. Hemorrhage is almost nothing. 
After delivery the bony fragments come 
in contact and sutures for this purpose 



are unnecessary; the soft parts must be 
sutured. The after treatment is very 
simple. — Le Bulletin Medical, Jan. 11, 
1892. 



Fatal Suppuration Beneath the 
Shoulder=Blade.* 

F. A. Treskin, (Med. Rundschau, 1890) 
Suppuration beneath the shoulder-blade is 
of rare occurrence, indeed, so rare that the 
author after searching numberless text 
books in the German and French Litera- 
ture, was unable to find any mention made 
of it, except a slight allusion to it in 
Hyetl's Anatomy. 

The case which he reports was as fol- 
lows: — The patient, a marine, was ad- 
mitted the 29th of July, into the Laza- 
retto, with symptoms of acute fever, 
sensations of heat and cold, headache, etc. 
There was present diarrhoea and the ther- 
mometer registered 38.8, and in the even- 
ing, rose to 39.5. The following day acute 
pains appeared in the right arm, the pa- 
tient coughed, the axillary glands were 
swollen and painful and there was some 
bronchial breathing. On the fourth day 
the entire right side, beginning from the 
median line in the back was swollen. At 
the point where the swelling was most 
reddened an exploratory incision was made 
down as far as the ribs : There was no 
pus present, only a slight discharge of 
bloody serum. Fluctuation could not be 
demonstrated. Anthrax was thought of, 
yet the microscopical examination did not 
corroborate it. The temperature now be- 
came sub-febrile, the pulse became slower 
until the fifteenth day when the patient 
died. 

In closing Treskin lays stress upon the 
difficulty of the diagnosis and presents the 
illness as one of great gravity, particularly 
when the abscess lies in the deeper struc- 
tures. 



Little Bessie had been taken in to see 
her new brother for the first time. " Do 
you think you will like him, Bessie ? " 
asked her father. 

" Why, yes," she said, clapping her 
hands delightedly. "There isn't any 
sawdust about him at all, is there ? He's a 
real meat baby." 



* Translated for The Medical and Surgical Repor- 
ter, by W. A. N. Dorland, M. D. 



* Translated for The Medical and Surgical 
Reporter, by Marie B. Werner, M. D. 



January 28, 1893. 



Abstracts. 



145 



ABSTRACTS. 

RELATION OF RHEUMATISM AND CHOREA. 



Dr. Townsend (Archives of Pediatrics) 
in discussing this subject before the 
American Pediatric Society, says: — 
' * Whatever the exact relations of chorea 
and rheumatism may be, it seems to me 
that a study of cases like these teach us 
the very practical lesson that in a choreic 
child we should be wide-awake to any in- 
definite pain as evidence of rheumatism, 
and should treat it accordingly, and that 
we should be particularly watchful for en- 
docarditis/' 

As a summary he offers the following- 
deductions. 

1st. Fright, eye-strain j debility, and 
school-pressure, particularly the latter, 
which often include some of the former, 
are potent exciting causes of chorea. 

2nd. Rheumatism, although absent 
from the history of at least half of the 
choreic patients, occurs with greater fre- 
quency among the choreic than the non- 
choreic cases. 

3rd. There is an intimate relation be- 
tween chorea and rheumatism. 

4th. The heart murmur so frequently 
found in chorea, sometimes associated with 
chorea and sometimes not, is in a consid- 
erable proportion of the cases due to en- 
docarditis, and leads to organic valvular 
disease. 

Dr. Orandall is of the opinion that the 
relation between rheumatism and chorea 
is a very close one and the question arises 
whether there is any chorea without rheu- 
matism. Is there such a disease as fright 
chorea or hysterical chorea? I believe that 
there is, in the same sense that there is a 
rheumatic chorea. A study of the dis- 
ease leads strongly to the belief that there 
is some underlying predisposing cause 
aside from rheumatism, fright, or hysteria. 
A dozen children have rheumatism and no 
chorea. The thirteenth has a mild attack 
of rheumatism and develops a severe 
chorea. The children in certain families 
are almost certain to have chorea if they 
contract rheumatism. Ten children are 
frightened by a dog and never have 
chorea; the eleventh at once develops a 
nervous disorder which increases in sever- 
ity for two weeks and lasts for six months. 
A hundred children are scolded by their 



mothers with no perceptible results of any 
kind. One of toy patients was scolded by 
a mother who had herself had chorea and 
at once developed an attack. That there 
is some predisposing neurotic element 
underlying all this I thoroughly believe. 
What it is I do not know. Not every one 
exposed to the bacillus of tuberculosis ac- 
quires the disease. That indefinite fac- 
tor we call predisposition is lacking. 
Not every child suffering from rheu- 
matism or subjected to fright has 
chorea. He is not predisposed to it. I 
should class rheumatism, fright, hysteria, 
excitement, pregnancy, not as all-powerful 
agents for the production of this disorder 
but rather as exciting agents for the pro- 
duction of a disease in subjects predis- 
posed to it, the most universal and potent 
of which is rheumatism. 

Dr. Adams in discussing this question 
presents the history of fifty cases of chorea 
treated at the Children's Hospital in Wash- 
ington from which he draws the following 
conclusions. 

1. That chorea is due to rheumatism 
in but a small percentage. 

2. That the heart murmurs are haemic 
in the largest number of cases. 

3. That the successful treatment would 
seem to exclude latent or apparent rheu- 
matism. 

4. That anaemia and chlorosis are well 
marked in nearly all cases. 

5. That nerve impoverishment is by 
far the most potent factor. 

Dr. William Osier, in closing, says, it 
seems quite impossible to bring all the 
cases of chorea into the category of rheu- 
matism. Our German colleagues, as you 
know, have not found more than some- 
times ten per cent., sometimes fifteen per 
cent. In the large number of cases which 
I have analyzed, and the great propor- 
tion of them I have gone over myself with 
especial care with reference to the history 
of growing pains, in 554 cases there were 
only fifteen per cent, with a positive his- 
tory of articular trouble. Including those 
with pains of any kind whatever the per- 
centage was only twenty which comes to 
about the percentage given by Dr. Town- 
send. Unless we largely expand our con- 



146 



Abstracts. 



Vol. lxviii 



ception of rheumatism in children the 
cases which have come under my observa- 
tion in Philadelphia and Baltimore, cer- 
tainly the large proportion of them, there 
is no definite history of rheumatism, and 
the absence of the subcutaneous fibroid 
nodules which our Englisn colleagues lay 
such stress upon is particularly striking. 
The only instances I have seen in this 
country have been in adults, not in chil- 
dren. 

The only other point I would refer to is 
as to the really remarkable frequency of 
organic heart disease in the subjects of 
chorea. In the 110 cases from the In- 
firmary of Nervous Diseases in Philadel- 
phia every one of which had had chorea 
two years prior to the examination, there 
were 54 with signs of organic heart di- 
sease existing. I do not mean 54 with 
heart murmurs. There are plenty of 
people with heart murmurs who have not 



heart disease, but signs of enlargement of 
the heart and murmurs of such a character 
as go only with organic valvular disease ; 
and in more than fifty per cent, of these 
cases there has been no history of rheuma- 
tism. 

A point referred to by Dr. Townsend is 
the extreme frequency of endocarditis in 
chorea. There is no other disease with 
which endocarditis is known to be so fre- 
quently associated, no other disease the 
post-mortem records of which show 
such a large proportion of endocarditis. 
The nature of the disease and its relation- 
ship are still doubtful, but the points 
which have been brought out here are of 
considerable interest and show I must say 
a larger percentage of rheumatic cases 
than has yet been shown in any series in 
this country, approaching much more to 
the English than to the German percen- 
tage. 



HYDEOOEPHALUS. 



Dr. A. Jacobi in speaking of Hydro- 
cephalus (Archives of Pediatrics) states 
that in the normal baby's head, 
while the fontanelles are open, you 
can count the pulse there better than at 
the radial ; you can see the pulsations. But 
as soon as hydrocephalic effusion takes 
place to any extent, this pulsation of the 
fontanelle ceases. 

In most cases, hydrocephalus, is either 
congenital or acquired early. When it is 
congenital, the brain is never fully devel- 
oped, while the skull may be too large, or 
normal, or too small, at birth. Such a 
case may be the result of an embryonal 
inflammation, though no positive evi- 
dence of it can be found. The ependyma 
is -often found thickened. The serum 
contains but little albumen, about one- 
tenth of a part per mille. Many such cases 
have been attributed to the obstruction of 
the aquaeductus sylvii, or to that of the 
foramen magendie; in others they have 
been found normal. Inebriety and sy- 
philis of the parents have been charged 
with producing congenital hydrocephalus. 
It is often found in numbers in the same 
family. 

Acquired hydrocephalus is inflamma- 
tory in most cases; that appears to be 
proven by the condition of the serum 



which — very much like that of transuda- 
tion and exudation — contains one per 
mille and much more of albumen. It is 
the result of interrupted circulation, for 
instance by the obstruction of the venar 
magna Galeni or the sinus recti, brought 
about by exudation or by tumors, or by 
slow circulation through chronic hyper- 
emia depending on general rhachitis. In 
a number of cases it has depended upon 
the presence of a tumor which has com- 
pressed a large vein, thereby giving rise to 
an effusion of water. In many cases, 
however, it is an inflammatory product, 
and the earlier it occurs, say during foetal 
development, the more detrimental are its 
effects. The immature, soft, and flabby 
brain is compressed and injured or de- 
stroyed. I have seen a whole hemisphere 
wanting, the meninges being filled with 
absolutely nothing but water. In a num- 
ber of cases the lateral ventricles are filled 
to such an extent that while the head is 
very large, the brain is atrophied, and 
sometimes nothing is left but a thin layer 
of cerebral tissue. These are the worst 
cases; as I said, the sooner the process 
begins the worse they are. 

When it comes to treatment, you can do 
much more for those that are acquired than 
you can for those which commenced in foetal 



January 28, 1893. 



Abstracts. 



147 



life. When the commencement was in 
early foetal life there is very little brain 
tissue, and almost every one of such cases 
will slowly die. Acquired cases may be 
benefited, particularly when they go with 
rhachifcis. Tincture of iodine, iodoform 
ointment and vesicatories have been ap- 
plied over the cranium, all to no purpose ; 
the iodide of potassium has been given 
without benefit, for where there is no 
brain there can be little response, new ef- 



fusion will take place all the while, and 
the result of treatment is very insignifi- 
cant. The same must be said of vesica- 
tories, purgatives, and diuretics. It has 
been proposed to tap the brain. A num- 
ber of recoveries have been reported from 
this practice. I cannot say that I have 
ever succeeded in curing one by this 
method, with or without the injection of 
iodine, which has also been proposed and 
practiced. 



VAGINAL HYSTERECTOMY FOR CANCER WITH REPORT OF FOUR 

CASES. 



Dr. Noble remarks that as the opera- 
tion of hysterectomy is not conceded by 
the profession in general, to be the logical 
means of eradicating cancer of the uterus, 
too much stress cannot be laid upon the 
importance of reporting all cases operated 
upon, and the final results — whether cure 
or recurrence. And the value of the op- 
eration, should be determined by the work 
of the few skilled surgeons — who have re- 
duced their mortality to five per cent. — 
rather than by the results obtained by 
a great number of surgeons, many of whom 
are inferior operators, if not absolutely 
bad ones. Vaginal hysterectomy being 
such a compartively new operation, suffi- 
cient time has not elapsed to place on re- 
cord the remote results of any large num- 
ber of cases. The statistics of certain 
German clinics attest a permanent cure 
in about forty per cent, of cases. As the 
laity and many also of the profession are 
proverbially hard to convince as to the 
efficacy of new operative measures — par- 
ticularly when asserting the probably per- 
manent cure of the much-dreaded cancer — 
it is of the utmost importance that all sur- 
geons report all cases under their charge, 
and make additional reports from year to 
year, until it can be definitely shown that 
cancer of the uterus is curable. The 
theory of climacturic hemorrhage is, most 
unfortunately, still believed in by a large 
majority of the public, and many profes- 
sionals as well. By experienced surgeons 
and gynecologists such hemorrhage is 
now acknowledged to be entirely abnormal 
and indicative of some gross disease of the 



* Read at a meeting of Phila. Obstet. Soc, Jan. 
5th, 1893. 



uterus, — cancer, fibroid tumor, or hyper 
plastic endometritis. 

Were this fact generally recognized, the 
first great step toward the cure of cancer 
of the womb would be taken, as it could 
be diagnosed and removed in its earliest 
stage, — making a cure almost certain. 
The following is the report of four cases 
operated upon by Dr. Noble — they being 
the only ones out of seventy-five cases 
which were not too far advanced for oper- 
ation. Of these four cases, three of the 
women were multipart, and the other had 
had a single premature labor. The com- 
mon history was purulent and profuse 
leucorrhoea, with more or less pelvic pain. 
The first case having small epithelioma of 
the cervix, was operated upon in May, 
1889, cervix being amputated. In No- 
vember of the same year, as the growth 
continued, vaginal hysterectomy was per- 
formed, allowing the ovaries to remain. 
Up to January 2nd, 1893 she was in robust 
health, and snowed no symptoms of a re- 
currence of the disease. The second case 
was malignant adenoma; operation, re- 
moving uterus and ovaries, took place 
January 5th, 1892, and up to the present 
the patient's condition is satisfactory. 
Number three was also a case of epithe- 
lioma of the cervix. The uterus and ovaries 
were removed October 5th, 1892, and the 
present condition of patient satisfactory, 
although she experiences some pain caused 
by an exudate about the left ovarian 
stump. Case number four, — epithelioma 
of cervix — operation December 21st, 1892. 
The left ovary was converted into a cys- 
toma which was ruptured in the removal; 
peritonitis immediately followed and death 
occurred on the fifth day. 



148 



Abstracts. 



Vol. lxviii 



Dr. Carl Koller (New York Med. Jour.) 
in speaking of " The Subconjunctival Ap- 
plication of Cocaine in Eye Operations," 
states that his suggestions, made some eight 
years ago, as to the use of instilla- 
tions of cocaine solutions to produce 
anaesthesia for operations on the eyeball 
met with general approbation, and subse- 
quently the usefulness of cocaine in other 
branches of surgery was explored by other 
investigators. He states in part: — 
' ' Right in my first experiments with ani- 
mals, and later in eye operations, I noticed 
the fact that by instillations of cocaine we 
were sure to achieve an anaesthesia of the 
superficial tissues only. I could scratch, 
or burn, or cauterize the cornea with- 
out the slightest pain, but the moment the 
iris prolapsed or was touched with an in- 
strument, animals and human beings gave 
brisk signs of pain. In a great number of 
cases I succeeded in making the iris 
anaesthetic by beginning the instillations 
half an hour before the operation, but I 
did not succeed every time. In my visits 
to eye clinics of different countries I found 
that only in a very few of them were in- 
stillations begun a sufficient time before 
the operation to achieve this end. This 
circumstance, in my opinion, detracts from 
the value of cocaine anaesthesia in a great 
number of eye operations. The patient 
does not care which tissue hurts him. 
He says he has pain, and calls cocaine 
anaethesia a beautiful but delusive dream. 
The pain on touching the iris is especially 
troublesome in cataract extractions. The 
patient, who has been promised a painless 
operation and did not experience any pain 
in cutting the cornea, is suddenly thrown 
out of his illusions of a painless operation, 
makes sometimes a sudden jerk, and may 
thus endanger the success of the opera- 
tion. 

In squint operations one can notice 
every time that the patient does not feel 
the conjunctival cut, but does react 
quickly when the tendon is seized with the 
hook or forceps and divided. 

Very soon after my first communication 
I began using subconjunctival injections 
in squint operations. 

I proceed in the following way: After 
having rendered the conjunctiva anaesthetic 
by the instillation of a four per cent, solu- 
tion, I insert the speculum and, by means 
of a mouse- toothed forceps, seize a fold of 
the conjunctiva over the tendon to be 



operated upon. The needle of a hypoder- 
mic syringe is inserted through this fold 
into the subconjunctival tissue as deep as 
possible, and a few drops of a two-per- 
cent, solution of cocaine are injected. 
For injections I use a two per cent, solu- 
tion in preference to a four or five per cent, 
solution. I consider 0.05 (two thirds of 
a grain) as the utmost limit for adults that 
can safely be applied as an injection if the 
locality of injection is on the head, while 
on the limbs double the amount may be 
allowed. But I am careful to keep a good 
part within this limit. With a solution 
of two per cent., and even of one per 
eent., an entirely satisfactory anaesthesia 
can be produced if the solution is well 
distributed over the field of operation, 
and I attribute it to this use of weak solu- 
tions that I have not encountered yet any 
alarming accidents from the use of cocaine. 

After the injection the speculum is re- 
moved from the eye and the eye is closed, 
so that the artificial oedema of the con- 
junctiva is given time to disappear, which 
it does in about five minutes. The disap- 
pearance may be helped by a little rubbing. 
If you have prepared a patient in this 
way, you can perform the operation with- 
out the slightest pain — whether it be 
tenotomy or advancement." 



Peroxide of Hydrogen. 

CHAS. MARCHAND REFUTES THE STATEMENT OP 
PROF. A. JACOBI. 

My attention has been called to an arti- 
cle read before the " American Pediatric 
Society," at Boston, May 4th, 1892, by 
Professor A. Jacobi, M. 3D., and published 
in the December number of The Archives 
of Pediatrics. This article is entitled, 
"Note on Peroxide of Hydrogen," and 
purports to be a " warning." 

The learned writer endeavors to convey 
the impression that, peroxide of hydrogen 
(medicinal) is a "nostrum," and that the 
manufacturer of this article is to be classed 
among " quacks and patent medicine ven- 
dors." 

Dr. Jacobi mentions several cases of 
diphtheria, which having been apparently 
greatly relieved by the use of peroxide of 
hydrogen (medicinal), finally were cured un- 
der th e use of lime water, as a spray and wash. 

The inference drawn by the writer of 
the article in question is, that the peroxide 
was an "irritant" and had been of more 
harm than good. 



January 28, 1893. 



Library Table. 



149 



It is not my province as a chemist to 
enter into a medical discussion with the 
learned dootor but I would like to ask if, 
in his opinion, a case of diphtheria can be 
treated successfully with lime water only, 
and whether in the cases he cites, it is not 
possible that the peroxide treatment was 
an important element in the recovery of 
these patients. I would also inquire 
whether the intemperate and in some in- 
stances personal allusions to myself and 
the preparation which I manufacture, are 
in all respects the outcome of professional 
investigation, and not the result of a desire 
to advertise himself by discrediting a 
remedy of which the therapeutic value has 
been proved by thousands of physicians 
who, though they may be "unsophisti- 
cated" from Dr. Jacobi's standpoint, 
are nevertheless known as eminent and 
honored professional men, all over the 
world. 

The drift of this article is seemingly an 
attempt to prove that peroxide of hydro- 
gen (medicinal) is injurious. 

In confutation of this, I append here- 
with, in as concise a manner as possible, 
the experience of a few prominent physi- 
cians whose statements may be taken as 
conclusive in the sense that they are 



learned and talented professional men, the 
equals of the writer who challenges their 
experience after having undoubtedly read 
their opinions, for every word I quote 
here has been published, and forms a 
prominent part of the medical literature 
of the day. 

In confirmation of my sincere belief 
that the claims made by me of the harm- 
less character of my medicinal peroxide of 
hydrogen are true, I am willing to submit 
myself to a thorougn test upon my own 
throat by spraying it with a twenty-five 
per cent, solution of Marchand's, perox- 
ide of hydrogen (medicinal) instead of a 
five per cent, solution as alleged to have 
been used by the doctor, for the same con- 
tinuous number of days mentioned by 
him ; and if any ulceration appears, or if 
the repeated applications of the remedy 
"does give rise to actual diphtheria," as 
he states may be possible ; then I am will- 
ing to acknowledge that he is right. This 
test may be made at any time with the ut- 
most publicity. 

I make this proposition in good faith 
from a scientific standpoint, and will ex- 
pect Dr. Jacobi to make the test in the 
same spirit or acknowledge that he does 
not desire to do so. 



THE LIBRARY TABLE. 



A Handbook of the Diseases of the Eye, and Their 
Treatment. By Henry R. Swanzy, A. M., M. B., 
F. R. C. S. I. Fourth edition with illustrations. 
[Philadelphia: P. Blakiston, Son & Co., 1892.] 

That the third edition of this work, pub- 
lished in October, 1890, should have been ex- 
hausted within two years and a fourth edi- 
tion called for, is positive testimony to its 
value. Although it is a small book compared 
with many similar treatises, the information 
contained in it is so well selected that one 
reads it with satisfaction. It is not so elabor- 
ate as to be wearisome, yet it is complete 
enough for a guide to the general practitioner 
and, in many instances, is sufficient for the 
specialist. The work possesses a distinctive 
character. It is the production of a mind 
capable of appreciating the essentials of 
Ophthalmology, together with the ability to 
present them in a clear and forcible manner. 

This fourth edition has been revised 
throughout and brought up to date. New 
means for accurate diagnosis are fully ex- 
plained, and new remedial measures are de- 
scribed in detail. 

While there is no endeavor to present a 
systematic account of the anatomy and 
physiology of the eye and its appendages, 



there are several interesting references to the 
results of recent investigations in these de- 
partments. Instances of this occur in Chapter 
xi, devoted - to " The motions >of the pupil in 
health and disease;" and in Chapter xviii 
upon " Amblyopia and amaurosis due to cen- 
tral and other causes." Two colored dia- 
grams of " The course of the optic fibres, with 
the centres of the three visual perceptions, 
and relations to fields of vision," illustrate 
the two theories of the macular nerve supply. 
One is that each macula is innervated from 
the opposite hemisphere; and the other, that 
the macula is supplied on the same plan as the 
rest of the retina, i. e., each side from the cor- 
responding side of the brain. 

The subject of treatment of the various dis- 
eases of the eye has received careful atten- 
tion throughout the book. Granular ophth- 
almia is referred to at considerable length, 
and the various methods of treatment are 
fully given. Squeezing out the granulations 
by means of Knapp's roller forceps is very 
favorably mentioned. 

A caution is given as to the use of 
jequirity, the author concluding his remarks 
upon it by saying that " the presence 
of well marked pannus of the cornea 



150 



Library Table. 



Vol. lxviii 



without ulceration is, I think, the only thing 
that can render the employment of jequirity 
justifiable, and, in addition to this, the con- 
junctiva should be free from blennorrhoea." 

In the treatment of corneal ulcers he does 
not write very enthusiastically of the use of 
miotics. He considers that they increase the 
tendency to iritis. Referring to the modern 
method of thoroughly cocainizing the eye 
before proceeding to operate for extraction of 
cataract, he says, that previously to the in- 
troduction of cocaine, general anaesthesia 
with ether or chloroform was commonly em- 
ployed in England . I never used it. " He in- 
sists upon careful attention to antiseptic meas- 
ures, before and during the operation. He pre- 
sents a very careful description of the " Three 
millimetre flap operation 11 for cataract ex- 
traction in which iridectomy is performed. 
In his defense of this "combined method," 
when discussing the subject of " Cataract Ex- 
traction without iridectomy, ' ' he says, "whilst 
admitting the charm of a circular pupil, I 
am of the opinion that the question is not 
whether the appearance of the eye is pleasing 
to us and to those who inspect them, but 
rather what advantrge the greatest number 
of persons operated on derive from the opera- 
tion. With sentimental talk about mutila- 
tion of the iris I cannot pretend to sympa- 
thize." 

In an appendix Holmgren's method for 
testing the color sense has been described in 
greater detail than before. 

Swanzy's Handbook bids fair long to hold 
its place upon the tables of our libraries. 



A Manual of Clinical Ophthalmology . By Howard F. 
Hansell, M. £>., and James H. Bell, M. D.., with 
120 illustrations, pp. 231. [Philadelphia; P. Blak- 
iston, Son & Co., 1892.] P. ice $1.75. 

The authors preface this manual by stating 
their purpose " to place before the undergrad- 
uate and general practitioner of medicine, a 
brief review of the anatomy, physiology, re- 
fraction, and common diseases of the eye." 
Right well have they performed their work 
forwe rarely meet with a book which contains 
so much accurate and valuable information 
condensed into so small a space. 

The first part contains a succinct account of 
the general Anatomy and Physiology of the 
eye. This is followed by other sections on 
Physiological Optics, Refraction, and Ocular 
Muscles. The remander of the book is de- 
voted to Diseases of the Eye and to Opera- 
tions. 

Although the description of each disease is 
concise, it is sufficient for recognition; and the 
treatment is shortly but emphatically given. 
There is no redundancy. All information is 
of the most practical character. 

This book of 231 pages contains no less than 
120 illustrations. As the authors frankly 
state, none of these are original, but their value 
has been greatly enhanced by the care which 
has been exercised in their selection and the 
excellent manner in which they have been 
reproduced. 

To the undergraduate and general practi- 
tioner, for whom it is prepared, it will prove 



an excellent introduction to more exhaustive 
treatises on the subject. One recommenda- 
tion is the low price at which it is published. 



Appendicite et Perityphlite , Ch. Talamon; Pleurisies 
Purulentes, Debove et Court ois- Suffit; Le Rachitisme, 
J. Comby. 

Dr. Talamon has written for the " Bibliothi- 
que-Medical Charcot Debove," an excellent 
monograph on "Appendicitis and Perityphli- 
tis. He discusses the history of the observa- 
tions from the case published by Negeler in 
1813, to the latest histories and operations of 
Treves, Oppenheimer, McBurney and Keen. 
Melier in 1827, suggested the wisdom and 
possibility of operation and reported three 
cases of perforating appendicitis. The whole 
subject is discussed intelligently with a 
thorough knowledge of the accumulated liter- 
ature of the last ten years, and a useful if 
perhaps too minute plan of sub-division of 
the various forms according to the anato- 
mical situation of the part primarily af- 
fected is suggested. The author insists, with 
Ashley of Baltimore, that unrecognized ap- 
pendicitis is more frequent in woman than is 
supposed. The activity of American sur- 
geons in this subject is well represented by 
numerous citations, and Dr. Talamon gives 
them full credit, while disagreeing with what 
he thinks a too strong tendency on their 
part to early operation in preference to the 
conservative medical treatment he would 
follow. 

Another volume of the same series on the 
"Treatment of Purulent Pleurises" is by 
Debove and Courtois-Suffit. American sur- 
geons have not so large a share here, and in- 
deed scarcely appear at all. The authors 
have not written a polemic in favor of thora- 
centesis or lavage, but a calm discussion of 
the whole subject, with insistence upon the 
importance before operation of careful study 
of the individual case, especially by means of 
bacteriologic ex amination . ' ' When we know 
the variety of empyema, the nature of the 
pathogenic agent producing it and the viru- 
lence of this agent, we can deduce the prob- 
able course of the pleurisy; but above all we 
can choose the most reasonable method of in- 
terference." The study is divided under 
three heads, the evolution of medical ideas 
on the subject, the different useful operative 
procedures, and the methods applicable to 
each variety of purulent pleurisy. 

The third volnme of the same series which 
bears the apparently necessary name of 
Charcot, is on "Rachitis, 1 ' by Dr. Comby. This 
disease once fortunately uncommon among 
native whites in this country, is growing 
more frequent with the increasing pressure 
of our population. It is one of the maladies 
which has not been revolutionized by bacter- 
ial pathology, but the new interest in minute 
pathology and the new knowledge of the 
evolution, prophylaxis and treatment lends 
it interest. Like the other manuals already 
reviewed, this one is well up to the informa- 
tion of the day, and if on a matter of less 
active general moment, is none the less 
valuable for its clearness, simplicity and full- 
ness. 



January 28, 1893. .Current Literature. 



151 



Curious Questions in History, Literature, Art and Social 
Life; designed as a Manual of General Information. 
By S. H. Killikelly. In two volumes. Philadelphia: 
The Keystone Publishing Co., 1892. 

This is a valuable work. Nearly 600 ques- 
tions are propounded and answered. Prob- 
ably not one-twentieth of these questions 
could be answered off-hand and correctly by 
the best-informed person in any ordinary com- 
munity. How many readers know: "What 
noted warrior led his troops into battle after 
his death?" "What kind of a tub did 
Diogenes live in?" "What is the Key of 
Death?" "What city was destroyed by 

( silence?" "When was ecstasy an infectious 
disease?" These sample questions selected at 
random, are answered fully, but not ful- 

; somely. 

It is a work for cultivated people, and the 
amount of useful information to be gained 



from its pages will amply reward the 
purchaser. 

The paper is good and the type clear and 
legible. " Curious Questions " is bound in two 
styles; one in dark green cloth, the other in 
half morocco. The latter style is illustrated. 



Medical Journal Advertising: A Manual for Adver- 
tisers. Edited by A. L. Hummel, M. D. Price one 
dollar. Published by Hnmmel & Parmele, 612 Drexel 
Building, Philadelphia, 1892. 

Intending advertisers will find much of 
value, and all will be interested, in this book. 
A number of men, prominent in medical 
circles, contribute articles of real value. It is 
an educating book in the sense of showing the 
benefits of advertising, and in teaching the 
advertiser how to word and place his an- 
nouncements to the best advantage. 



CURRENT LITERATURE REVIEWED. 



PACIFIC MEDICAL JOURNAL. 

Dr. Fred. W. D' Evelyn contributes a paper 
on " The Right Heart in Circulatory Obstruc- 
tion," in which he cautions against the use of 
digitalis and its fellow s in those cases where 
the right heart is engorged, and the left side 
really depleted through the venous engorge- 
ment and lack of arterial blood. 

Dr. A. W. Perry, in his article on the " Surg- 
ical Treatment of Puerperal Endometritis," 
advises the use of the curette followed by an 
antiseptic douche in puerperal sepsis, es- 
pecially those cases where there may be re- 
tained portions of placenta or membranes. 

The number concludes with an account of 
" Receiving Hospital of San Francisco," by 
Dr. Tenison Deane. The hospital is under 
the charge of the Board of Health, and has 
accomodations for about twenty patients be- 
sides a ward for alcoholic cases. A surgeon 
is constantly in attendance; fractures are 
treated; fractured skulls are trephined; lap- 
arotomy is done for stab and gunshot wounds 
" In fact every conceivable injury is treated 
at the hospital during the year." 

VIRGINIA MEDICAL MONTHLY. 

Dr. J. M. Baldy's article on " Uterine Fi- 
bromata " gives his experience in hysterec- 
tomy. He has removed twenty-seven tumors 
with two deaths. He pursues the supra- 
vaginal extra-peritoneal method, and com- 
mends that as being the most uniformly suc- 
cessful. 

Dr. John Dunn reports two cases of " Con- 
gen tial Chorea." Dr. N. L. Guice reports a 
case of " One-sided Swelling of the Face," as 
the result of malaria. 

Dr. William C. Dabney contributes a clini- 
cal lecture on "Valvular Disease of the 
Heart," and defines the indications for digi- 
talis in such cases. There is also a report of a 
" Aneurism of the ascending arch of the 
Aorta," by Dr. Llewellyn Eliot. " Dysen- 



tery, Its Prevalence and Treatment," is the 
title of a paper by Dr. L. Ashton. Dr. George 
Corrie describes an improved "Urethrotome," 
made after the well known Otis instrument, 
but differing from it in having a bulb at the 
distal end of the upper bar of the shaft, which, 
Dr. Corrie claims, besides sheathing the knife, 
" defines the tissue to be cut, avoiding the an- 
noyance and uncertainty of having to take 
measurements." There is also an indicator 
attached which shows accurately the move- 
ments of the blade. 

Dr. Chas. G. Cannaday advocates the use 
of the galvanic current, with faradization, as 
a " Uterine Developer," giving the report of 
two cases treated in this way. He claims 
that, by this method, the uterus is stimulated 
to take on new growth, the menstrual func- 
tions are restored, and dysmenorrhcea and 
sterility cured. [Tonics and carefully regu- 
lated hygiene are also part of the treatment 
and, in the minds of some, will be accredited 
with the improvement noted and not the 
electricity. — Ed.] 

MONTREAL MEDICAL JOURNAL. 

Dr. W. Johnson reports a case of extensive 
fracture of the skull as the result of a " Gun- 
shot wound through the orbit." The report 
is interesting from a medico-legal point of 
view and Dr. Johnson gives the result of sev- 
eral experiments on the cadaver, made to 
show the injuries on the skull that would be 
received by the discharge of a load of shot 
through the orbit at close range. 

Dr. Thomas R. Dupuis, in an article on 
" Goitre and its treatment," rejects surgical 
interference as likely to be followed, even if 
the patient survive, by cretinism and an 
enormous increase of mucin in the body or 
myxcedema. The various non-surgical meth- 
ods of treatment are discussed and, while the 
disease is fortunately rare in this portion of the 
country, the article is worthy of attention as an 
addition to our knowledge of the subject. 



152 



Current Literature. 



Vol. lxviii 



Dr. J. A. Springle reports a case of " sym- 
physiotomy," performed for contracted pelvis. 
The forceps had been applied and failed to 
deliver. After division of the symphisis, 
forceps were again applied and a living child 
delivered. The number also contains an ad- 
dress by Sir James Grant, M. D., on "Queen's 
University and Medical Education." 



THE PHILADELPHIA POLYCLINIC. 

In the January number of The Philadelphia 
Polyclinic Dr. Baer calls attention to " The 
Danger of Delay in Pelvic Abscess. ' 1 Dr. Rob- 
erts offers a few remarks on " The Pathology 
and Treatment of Internal Hemorrhoids." 

Dr. Contrell having witnessed many mis- 
takes in the diagnosis of the two affections, 
" Psoriasis aud Syphilis," presents one case of 
each with a study of several features which 
are prominent in each. 



ARCHIVES OF PEDIATRICS. 

The January issue of the Archives of Pedri- 
atics contains an interesting discussion on 
" The Relation of Rheumatism and Chorea " 
by Dr. Townsend of Boston, Dr. Crandell of 
New York, and Dr. Adams of Washington, 
of which fuller mention is made elsewhere. 

Types of Infantile Syphilis. 

by Dr. Stowell, is deserving of a careful read- 
ing. In the treatment of these cases, he states 
that he has " fallen into a habit of using what 
proved good." Inunctions of oleate of mer- 
cury for infants, with mixed treatment to the 
mother, if nursing. Older children , especially 
in late manifestations, were given mercuric 
chloride in doses ranging from 1-120 to 1-32 
of a grain according to age. Mercury we find 
lauded in all forms. Calomel or grey powder 
is easily administered, but at times proves too 
laxative unless checked by an opiate. Inunc- 
tions of two per cent, of oleate of mercury, or 
of the officinal ointment, are better than inter- 
nal medication. Judicious feeding and gen- 
eral tonics must not be forgotten, for the evil is 
only removed by constant and long continued 
vigilance. 

A clinical lecture by Dr.' A. Jacobi on 
" Multiple Sarcoma," and " Hydrocephalus " 
completes the list of the more important 
papers. This number also contains an open 
letter from Mr. Marchand in protest to strict- 
ures upon Peroxide of Hydrogen made by 
Prof. A. Jacobi, in a former issue of this jour- 
nal. 

JOURNAL OF CUTANEOUS AND GENITO -URI- 
NARY DISEASES. 

For January the leading article offered is a 
new and successful mode of treatment in 
" Xanthoma Tuberculatum " by Dr. Morrow. 
It is illustrated by a chromo-lithographic 
plate which is of great assistance in elucidat- 
ing the subject. 

Dr. Blanc reports 

A Case of Skin Shedding, 

in which the epidermis of the hands and 
feet, particularly the former, came off almost 
without a break, resembling gloves and moc- 



casins. The nails were loose but did not 
come off at this time. The doctor believes 
that while, from the general character of the 
case, this is not a true type of dermatitis ex- 
foliativa, yet it resembles it sufficiently to be 
a variety of it. 

Dr. Hartzell has a carefully prepared paper 
on " Sarcoma Cutis." The subject matter is 
well illustrated. 



THE BRITISH JOURNAL OF DERMATOLOGY. 

The Journal of Dermatology for January 
contains but one article and that a monograph 
by Dr. Stephen Mackenzie, on 

Dermatitis Herpetiformis 

which is denned as a cutaneous neurosis char- 
acterized by the multiformity of its manifesta- 
tions, which may consist of erythematous, 
papular, vesicular, bullous, and urticarial 
eruptions, which may appear concurrently or 
sonsecutively and are usually attended with 
pigmentation of the skin; a grouping of vesi- 
cles is the most characteristic feature, and 
present in most cases at some part of their 
course; it is usually attended with great itch- 
ing and burning; it runs a chronic course 
with exacerbations, or relapses and intervals, 
and usually terminates spontaneously, but 
may end fatally; it is attended with some, 
but usually not serious, disturbance of the 
general health; it affects both sexes, and at 
all ages, but is most common in the middle 
period of life; in women it is often connected 
with pregnancy, but may occur independently 
of it." It is not surprising that such a poly- 
morphic disease should have received a variety 
of names. The author has adopted the pres- 
ent name, given the disease by Dr. Duhring, 
which seems the most generally accepted, as 
it is the most descriptive. 



Neuroses after Removal of Appendages. 

Debove (Nouv. Arch, d 1 Obstet. et de Gynec, 
1892) demonstrated at a recent meeting of the 
Societe Medicale des Hospitaux that removal 
of the appendages may do worse than fail to 
cure hysteria and pelvic pain. It may fail 
to prevent, and may even excite, a neurosis. 
A woman, aged 38, had her appendages re- 
moved in December, 1889. The ovaries were 
found "diseased." Her period did not re- 
cur. On June 28th, 1890, she had a severe 
nervous attack, which recurred. Debove ex- 
amined her during one of the seizures. There 
was right hemianaesthesia with the typical 
so-called ovarian pain in the iliac fossa. Thus 
this sympton may exist when no ovary re- 
mains. Compression over the region set up 
an attack, and the pain could be transferred 
by the application of magnetism. Desuos, 
in discussing the case, stated that he had 
twice seen insanity after ovariotomy. ■ Rendu 
noted that many abdominal operations were 
followed by the same result. He saw in- 
sanity commence in a woman a few days 
after an operation for artificial anus. The 
mental disease proved incurable and fatal. 
Mathieu had seen nymphomania after re- 
moval of the ovaries. — Br. Med. Jour. 



[ January 28, 1893. 



Periscope. 



153 



PERISCOPE. 



THERAPEUTICS. 



Dr. H. A. Hare {Therapeutic Gazette) 
recommends strychnine as a remedy for and 
the prevention of surgical shock, anaesthetic 
collapse and opium-poisoning. He states that 
it must be given in full doses or not all all. 
Not less than a twentieth of a grain should 
be used hypodermically every half-hour for 
an adult; and if the shock be marked, a dose 
of as much as a fifth of a grain may be given 
in this way. Disagreeble effects rarely fol- 
low, and will probably amount to no more 
than muscular twitching, which can be read- 
ily controlled by sedatives. In describing a 
visit to Professor Horsley's laboratory, he 
says that a monkey upon whom a brain ex- 
periment was being performed was placed in 
a water-bath and well covered to attain the 
proper heat. This is considered necessary for 
the survival of the monkey, and from it may 
be inferred that the application of heat about 
the body of a person undergoing an operation 
is of the greatest importance. The same is 
also true in cases of hemorrhage and shock. 
Experiments by Brunton show that animals 
poisoned with chloral die from doses, which, 
when artificial heat is given them, fail to 
produce dangerous symptoms. 



MEDICINE 

Actinomycosis Hominis. 

Dr. Justus Ohage in writing on this subject 
says that actinomycosis in man is one of the 
so-called modern diseases, that is, its recogni- 
tion, description and understanding are due 
to modern investigation and discoveries. 

The first to recognize this disease was James 
Israel, in Berlin, in 1878. He published his 
observations in Vol. 74, Virchow's Arehiv. 
Ponfick, of Breslau, gave a fuller description 
of it in 1879, and was the first to demonstrate 
that the disease in man was really due to a 
fungus, the actinomyces first discovered in 
1877 by Bollinger in the jaw of cattle. Since 
then numerous observations have been pub- 
lished and this disease has obtained full path- 
ological recognition. Actinomycosis is more 
frequent in Europe than here, at least it is 
oftener diagnosed and recognized over there; 
still the disease is common enough in this 
country to demand the attention of the medi- 
cal profession. 

The disease is produced by the entrance of 
a vegetable parasite or fungus into the sys- 
tem. The ray like arrangement of its elements 
caused Harz to name it actinomyces, "aktis," 
ray, " mykis," fungus. The experimental re- 
searches of Ponfick, DeBray and Pringsheim 
have conclusively shown that this fungus is 
the true causa morbi of the disease in question, 
and have proved the identity of it in man, 
cattle and hogs beyond any doubt. 

The diseases with which actinomycosis is 
most often confounded are tuberculosis and 



epithlial cancer. It gains its entrance into 
the system in various ways. The fungi may 
enter with various kinds of food, by inspira- 
tion, etc., and according to the channels 
through which they entered the system the 
symptoms of the disease make themselves 
manifest. We have thus actinomycosis of 
the lungs, the kidneys, the bowels, the stom- 
ach, etc. 

Most cases of actinomycosis in man have 
their starting point in decayed teeth and dis- 
eased tonsils. From here the fungus is dis- 
tributed through the organism and begins the 
destruction of the organs on which it has 
settled. The protean character of this disease 
is indigenous to man only, while in the lower 
animals, cattle and hogs, its predilection is 
for the jaw. There is another peculiarity — 
the tendency to the formation of tumors' in 
animals is entirely absent in man. On the 
contrary, the granular tissues produced by 
the phlogogenous action of the fungus tend to 
fatty degeneration and decay. In an insidi- 
ous and chronic manner the fungi penetrate 
the tissues, destroying them in their onward 
march, and unless the perforation of some 
vital organ as the stomach, or the bowels, or 
the lungs cuts life short, the mode of death 
is generally that by pyaemia. 

The diagnosis of the disease during life is 
comparatively easy if the ravages of the 
fungus are visible to the eye, as in the first 
two cases which I shall presently describe. A 
peculiar form of small yellow bodies is always 
found in the pus, fistulse and swellings; it is 
unmistakable after once having been seen. 
On microscopical examination they seem to 
consist of threads terminating in bulbous 
ends. The threads radiate from the centre, 
thus giving the fungus a ray-like appearance. 

When internal organs are attached, hidden 
from view and inaccessible to observation, 
the diagnosis is impossible. 

The prognosis and treatment of actinomy- 
cosis is based upon its indigenous properties. 
As it is a local fungus disease, not constitu- 
tional like syphilis and tuberculosis, it is 
curable if all the infected tissues can be re- 
moved. Where that cannot be done a fatal 
termination is inevitable. — Northwestern 
Lancet. 



Aural Symptoms of Neurasthenia. 

Dr. Suney Molist (Annates des Mai. de 
POreill, Dec, '92) offers an explanation of 
the annoying symptoms, in the form of sub- 
jective noises, which are so prominent in 
many cases of neurasthenia, and which are 
accompanied often by a considerable diminu- 
tion of the hearing by bone conduction. 
These cases of tinnitus are grouped by the 
author as follows: 

(1) Simple suspense of vaso-motor inhibition 
of the vessels of the cochlea, which, by their 
pressure upon the terminations of the acoustic 
nerve, cause a continuous tinnitus, which 
may be temporarily relieved by forcible com- 
pression of the carotid. 

(2) Patients who have previously had an 



154 



Periscope. 



Vol. Ixviii 



otitis, who are rheumatic subjects or who 
have an atheromatous condition of the vessels 
which once dilated do not readily return to 
their previous condition, the result of this 
continued dilatation being exudation into the 
membranous labyrinth or, possibly hemor- 
rhage. 

(3) Affection of the perceptive power of the 
internal ear as the result of the long con- 
tinued vaso-motor disturbance; in these cases 
the tinnitus gradually increases in intensity, 
as does also the impairment of hearing, and 
to these two symptoms is sometimes added 
vertigo. 



SURGERY. 



According to Rampoldi (Annual Univ. de 
Med.) there are five groups of sexual diseases 
which affect the eye, as follows: 

(1.) Hysteria and chronic metritis are cau- 
sative of asthenopia and retinal hyper- 
esthesia. 

(2.) Menstrual disorders. Amenorrhcea is 
causative of conjunctivitis keratitis, iritis and 
phlyctenule. To suppression of the menses 
he refers diseases of the choroid, with neuritis 
and retinitis. The tendency to glaucoma is 
known to accompany a sudden suppression. 

(3.) Inflammatory diseases occur in hyper- 
esthesia and neuralgias of the trigeminus. 

(4.) Pregnancy causes the difficulty accom- 
panying the albuminuria of that state. Am- 
blyopia and amaurosis have been common 
from three to fourteen days after hemorrhage. 

(5.) During lactation and the puerperium 
the following have been observed: Panoph- 
thalmitis, ulcers of the cornea, retinitis, pho- 
tophobia, disturbances of accommodation and 
other morbid conditions resulting from de- 
bility. 



Discriminating Diagnosis Between Cerebral 
Hemorrhage and Acute Softening. 



CEREBRAL HEMOR- 
RHAGE. 

1. Age, thirty to 
fifty. 

2. Hereditary his- 
tory of arterial dis- 
ease. 

3. Sudden onset 
with coma and par- 
alysis occurring to- 
gether, the coma 
deepening. 

4. Stertorous breath- 
ing, and hard, rather 
slow pulse. 

5. Peculiar alter- 
nate conjugate devia- 
tion of the eyes. 

6. Early rigidity. 

7. Convulsions. 

8. Initial subnor- 
mal temperature fol- 
lowed by a rise in 
twenty-four to forty- 
eight hours. 



ACUTE SOFTENING. 

1. Earlier or later 
age. 

3. Premonitory 
symptoms and more 
gradual onset or more 
transitory coma. 



6. Rarely occurs. 

7. Seldom present. 

8. No initial fall of 
temperature. But 
slight tendency to 
subsequent fever. 

9. Presence of weak 
heart or endocarditis. 
Slight hemiplegia 
with aphasia. The 
puerperal state. — Dr. 
Dana. 



Dr. Darrah (Boston Med. and Surg. Jour. 
Jan. 12, 1893) in a report of three cases of 
caries of the coccyx draws the following con- 
clusions: 

(1) That caries of the coccyx occurs very in- 
frequently. 

(2) That it is more common in females than 
males. 

(3) That there are these important points 
in considering the diagnosis of these cases: 
(a) history of injury; (b) constant pain; (c) 
multiple and persistent sinuses (not always 
present); (d) that persistent sinuses should 
lead one to suspect caries of the coccyx; (e) 
that excision of the coccyx is the best treat- 
ment for all cases when there is disease of 
that bone. 



The Early Extirpation of Tumors. 

In a paper read before the New York State 
Medical Association, at its recent meeting, 
Prof. J. W. S. Gouley presented the follow- 
ing conclusions on this subject: 

1. Malignant tumors exceed benign tumors 
in frequency. 

2. That malignant tumors comprise epithe- 
liomata, sarcomata and internal adenomata. 

3. Among the benign tumors myxomata 
and external adenomata often recur after in- 
cision, but do not infect the system. 

4. There is no solid benign tumor that may 
not become malignant. 

5. No means are known by which can 
be ascertained the precise time of the be- 
ginning of metamorphic action in tumors. 

6. Most malignant tumors have a stage of 
benignity. 

7. Excision of potentially malignant tumors 
in the early epoch of their stage of benignity 
is likely to effect a permanent cure, or at 
least to prolong greatly the period of im- 
munity from recurrence of the disease. 

8. In the excision of malignant tumors the 
greatest care should be taken to remove as 
much of the ambient tissue, including fasciae 
and lymph glands, as is compatible with 
good judgment. 

9. General treatment of tumors has no 
value except as an adjuvant of a surgical 
operation, and is often indirectly injurious, 
leading the patient to expect a cure by per- 
servering in the use of drugs, and thus al- 
lowing the disease to make rapid progress 
toward a fatal end. 

10. Local treatment of tumors, by means of 
escharotic plasters, pastes or powders, is the 
most fruitful in evil of all the devices for the 
torture of the afflicted. The plaster, paste or 
powder causes the greater part of the tumor 
to slough, but there is enough left behind for 
the most rapid extension of the disease. 
The effect of the escharotic is, therefore, only 
to till a soil where new growths sprout like 
so many seeds cast upon a rich loam. 

11. Compression is delusive in the case of 
tumors containing cysts, and is directly hurt- 
ful by exciting the rapid growth of most 
tumors. — At. Med. and Surg. Jour. 



iiij January 28, 1893. 



Periscope, 



155 



Treatment of Aortic Aneurysm by Electro= 
lysis through Introduced Wire. 

Stewart (Amer. Jour. Med. Scien., October, 

I 1892) reports a case of large sacculated an- 
eurysm of the aorta treated by the introduc- 
tion of wire and electrolysis. This treatment 
was tried with the object of promoting 
prompt formation of firm protecting coagula, 

i in order to retard rupture of the thin-walled 
sac. The aneurysm, which had arisen from 
the lower part of the thoracic aorta, and sub- 

: sequently had involved a portion of the ab- 
dominal aorta, was a very large one, and 

i bulged backwards so as to form a prominent 
pulsating swelling in the left lumbar region. 

i The patient was a man, aged 32. In his 
operative treatment of this case the author 
chose a rather heavy silver wire with the idea 
that the presence of large supporting spirals 
in the sac occupying much of the cavity, and 
affording a good framework for clot, would 
offer a better chance of immediate success 
than the use of a thinner and more pliant 
wire, which might undergo deflection from 
its course of introduction through coming in 
contact with loose coagula already in the sac. 
Two and a half feet of wire and also one end 
of a platinum needle were introduced into 
the sac, and a current, after being gradually 
increased to a strength of 70 milliamperes, 
was maintained at this point for one hour. 
The wire was passed through a canulated 
steel needle two and a half inches in length. 
The condition of both needles on withdrawal 
showed unquestionable clot formation about 
them. 

On the third day from the date of operation 
a remarkable change was noticed in the con- 
dition of the aneurysm. The prominent 
pulsating portion in the left loin had become 
depressed, and transmitted pulsation could 
be detected in it. The whole of the lower 
part of the aneurysm felt much firmer, and 
was quite without pulsation, while the ex- 
treme upper part seemed to have undergone 
no change. The patient, however, continued 
to suffer severely, and, on the ninth day, died 
very suddenly in consequence of the rupture 
of the sac. At the necropsy firm clots were ob- 
served in all portions of the aneurysm, to- 
gether with soft ones evidently of very recent 
origin. The wire was engaged in several 
large firm clots, which were of so solid a text- 
ure that when examined in that part of the 
sac which was removed they could not be 
separated from the sac and wire without 
some difficulty. 



OBSTETRICS. 

Asepsis and Antisepsis in the Lying=in 
Chamber. 

Potter makes the following propositions 
concerning asepsis in the puerperal chamber. 

1. Let us begin by making the patient as 
nearly clean as possible for soap and water to 
accomplish. 

2. Let her, prior the beginning of labor, 
have an immersion-bath daily for several days, 



and with the first manifestations of pains, 
let her abdomen and genitalia be rendered 
absolutely aseptic by further application of 
germicides in solution, adequate to accomplish 
the desired end. 

3. Let her have a warm vaginal douche, 
rendered aseptic. 

4. Let the lower bowel be thoroughly evacu- 
ated by copious lavements of hot water prior 
to the vaginal bath. 

5. Let her bedding be made as pure and 
clean as careful laundrying can make it. 

6. Let her clothing be made equally clean 
in like manner. 

7. Let there be a number of clean bichloride 
napkins placed in readinesss for use. 

If all of these injunctions are rigidly en- 
forced, we have done much to lay the founda- 
tion for a physiological labor. 

The physician and all the attendants must 
be rendered as scrupulously asceptic as the 
patient herself. The nurse must be especially 
trained in the habit of keeping her hands clean. 
After the first examination, which should be 
made as carefully and deliberately as possible, 
the physician should refrain from further ex- 
amination unless absolutely required. 



Suckling and Quinine. 

Oui {Arch de Tocologie et de Gynec, De- 
cember, 1892) finds that when the mother or 
nurse takes quinine it has no ill effect on the 
child. The drug is certainly excreted with 
the milk, but in very small quantities. The 
quininised milk has absolutely no influence 
on the child. After a series of careful weigh- 
ing and measurement, it was found that the 
average was the same in children suckled for 
a given time by nurses who had taken qui- 
nine as in children whose nurses had not 
taken that drug. Hence a nurse or mother 
may safely take quinine. Burdel's theory 
that quinine is noxious to the child is incor- 
rect, and the precautions which he recom- 
mends are therefore unnecessary. — Brit. Med. 
Jour. 



Missed Abortion. 

Liebmann, of Buda-Pesth (CentralbL f. 
Gynak., No. 38, 1892, from the Arvosi Het- 
ilap), relates a case in which the remains of 
a foetus which had died in utero were dis- 
charged piecemeal. A three-para suffered at 
the fourth month of pregnancy from a foetid 
sanious discharge, which lasted for two 
weeks ; then pieces of foetal bone began to 
come away. The process took about seven 
months, with intervals corresponding to the 
greater or less strength of the uterine con- 
tractions. Some of the bones were dis- 
charged singly ; some remained articulated 
and required forceps for their removal. The 
placenta came away four and a-half months 
after the beginning of the abortion. The 
number of bones that were thus gradually 
delivered amounted to over seventy, and in- 
dicated that the foetus had reached the third 
month. — Ex. 



156 



Periscope. 



Vol. Ixviii 



GYNECOLOGY. 



Fatal Rupture of Pyosalpinx: Suspected 
Abortion. 

Rochet (Journ. d'Aecouchements, 1892) 
recently described a case of rupture of a pyo- 
salpinx from rough handling during the ap- 
plication of the curette to the uterine cavity. 
He adds a yet more instructive case. A 
female servant, aged 26, was admitted into 
hospital, losing blood. She fancied this 
might be due to a miscarriage at the first 
month, which she believed to have occurred 
on the previous evening. The uterus seemed 
normal. A tender mass of the size of a small 
egg, lay in Douglas's pouch. A few days 
later the patient insisted on leaving the hos- 
pital. She was therefore examined first; the 
mass was found smaller and less tender; at the 
time the examination caused no pain. Pyo- 
salpinx was diagnosed, and the patient, in- 
stead of leaving the hospital, remained, and 
an enema with a dose of castor-oil was given 
in view of an operation. In the evening the 
patient became very ill. Next morning an 
exploratory operation was performed. Pus 
escaped freely when the abdomen was 
opened. Douglas's pouch was laid open and 
drained. The patient died in a few hours. 
There was a judicial inquiry owing to a sus- 
picion that she had died from attempted 
abortion. There was no doubt that the cause 
of her death was rupture of a pyosalpinx. 
The uterus showed signs of recent early preg- 
nancy. There was no evidence of criminal 
abortion. Rupture of a pyosalpinx is no 
doubt the cause of many mysterious deaths 
after curetting, dilatation of the uterus, etc., 
when the uterus is dragged downward, or 
pushed upward with violence.— Brit. Med. 
Jour. 



ARMY AND NAVY. 



FROM JANUARY 15, 1893, TO JANUARY 21, 

1893. 

First Lieutenant Thomas U. Raymond, As- 
sistant Surgeon, is relieved from further duty 
at Vancouver Barracks, Washington, and 
will report in person to the commanding 
officer Fort Canby, Washington, for further 
duty at that station, relieving Captain 
Edward C. Carther, Assistant Surgeon, who 
on being thus relieved, will proceed to 
Vancouver Barracks, and report in person to 
the commanding officer of that post for duty 
there. 

Captain Guy L. Edie, Assistant Surgeon, 
U. S. Army, is relieved from duty at Fort 
Neobrara, Nebraska, and will repair to New 
York City, New York, and report in person 
to the attending surgeon in that city, for duty 
in his office. 

Leave of absence for four (4) months, is 
granted Captain Jefferson D. Poindexter, As- 
sistant Surgeon, U. S. Army. 



NEWS AND MISCELLANY. 



One of the Ways by which Corporations 
Reduce the Income of the Medical 
Profession. 

In general it may be said corporation exist 
to reduce to the lowest possible degree the 
incomes of all with whom they deal. On 
former occasions we have called attention to 
the effect of railroads upon the income of 
surgeons. But just now we desire to call at- 
tention to the influence of accident insurance 
companies in diminishing the income of the 
profession. 

Formerly when one of the employes of a 
manufacturing establishment was injured, 
either the employe called upon his own doc- 
tor or the company sent him to a well known 
practitioner. After recovery, either the man 
paid the doctor what he was able to, or the 
company paid the bill. In either case the 
doctor got a reasonable reward for his work 
and responsibility. Lately companies have 
been formed that agree for a certain sum to 
look after the injured employes. The results 
of this plan are that the accident company 
deliberately sets about to*cheat the doctor out 
of his fee for service. It employs men 
adapted for this particular purpose. If they 
fail in other ways, they dump the patient into 
the charity ward of a hospital, paying his 
board and making the hospital doctor do the 
work for nothing. In the aggregate the 
money thus lost to the profession and put 
into the pockets of the accident insurance 
company is very large. 

In this case we do not see any way by 
which this leak can be stopped, because all 
doctors, will not combine to prevent it. In a 
different form, it is the same as with the rail- 
road doctors. All will not agree in refusing 
to do the work without fair compensation . 
In each case, if one refuses, another takes his 
place on the terms offered by the corporation. 
In the contest between doctors and corpora- 
tions, the latter take the money and keep it, 
while they leave for the doctor all the glory. 

As to the benefit to employes, the following 
is [significant. The writer, observing a dan- 
gerous condition of a freight elevator, directed 
the attention of the proprietor to it. He 
carelessly replied that it made no difference 
to his house, as a casualty insurance com- 
pany was paid to protect the firm from all 
damages. — American Lancet, Nov. 1892. 



Popular Tours to Washington. 

Personally conducted tours to Washington 
have been arranged via Royal Blue Line, to 
be run at frequent intervals from New York 
and Philadelphia to Washington. The next 
excursion will be on February 2nd. For pro- 
gramme describing these tours, write to Thos. 
Cook & Son, Agents B. & O. B. R., 261 and 
1225 Broadway, New York, or 332 Washington 
Street, Boston. 



Vol. LXVIII, No. 5. 
Whole No. 1875. 



FEBRUARY 4, 1893 



$5.00 per Annum 
10 Cents a Copy 



A WEEKLY JOURNAL. 



THE 



Established 1853, by S. W. Butler, M. D„ 



MEDICAL AND SURGICAL 



REPORTER % 



p. o. box 843, pHAM pa, 



Entered as Second-Class Matter at Philadelphia P. O. 



ORIGINAL ARTICLES. 

W H. Link, A. M., M. D., Petersburg, Ind. 
Object Lessons in Gynecology 



Toseph Hoffman, M. D., Philadelphia. 
The Salient Points in Appendicitis-Its Diagnosis 

and Treatment 

CLINICAL LECTURES. 
William Goodell, M. D. 
Prolapse of the Womb from Hypertrophic Elon- 
gation of the Supra-Vaginal Portion of the Cervix 
—Supernumerary Ovary with Ventral Heinia— 
Pyo-Salpingitis— Nervous Ovaries 

COMMUNICATIONS. 

G A. Wall, M. D., Topeka, Kansas. 
Abscess of Frontal Sinus— Report of Case— Opera- 
tion 

J S Wright, M. D., Brooklyn, N. Y. 
An Attempt to make a Radical Cure in Three Cases 

of Hernia 

L S McMjtrtry, M. D., Louisville, Ky. 
Two Cases of Suppurative Intra-Pelvic Inflammation 
with Specimens 



1G0 



166 



SOCIETY REPORTS. 

The Clinical Society of Louisville . 

EDITORIAL 

An Agnew Memorial 

TRANSLATIONS 

ABSTRACTS 

THE LIBRARY TABLE 

CURRENT LITERATURE 191 

PERISCOPE 

MEDICINE .... 194 

SURGERY 194 

OBSTETRICS 196 

GYNECOLOGY 196 

NEWS AND MISCELLANY m 



178 
180 
18G 
191 



NO OPENERS 

FOR CHAMPAGNE REQUIRED 



By means of a small seal attached to wire, the latter can be 
broken and easily removed by hand, together with top of cap,, 
on G. H. MUMM & CO.'S Extra Dry. 

G. H. Mumm & Co. having bought immense quantities of the 
choicest growths of the excellent 1884, 1887 and 1889 vintages, 
the remarkable quality and delicious dryness of their Extra Dry 
can be relied upon for years to come. 

4 'By chemical analysis the purest and most wholesome cham- 
pagne." — R. Ogdkn Dors mus, M. D., LL-D. 
p s Professor of Chemistry, N. K. 




The Demand For 

a pleasant and effective liquid laxative has long existed — a 
laxative that would be entirely safe for physicians to prescribe 
for patients of all ages — even the very young, the very old, the 
pregnant woman, and the invalid — such a laxative as the physi- 
cian could sanction for family use because its constituents were 
known to the profession and the remedy itself had been proven 
to be prompt and reliable in its action, as well as pleasant to 
administer and never followed by the slightest debilitation. 
After a careful study of the means to be employed to produce 
such 

A Perfect baxative 



the Califor ia Fig Syrup Company manufactured, from the juice 
of True Alexandria Senna and an excellent combination of car- 
minative aromatics with pure white sugar, the laxative which is now so well and favorably known under the 
trade name of " Syrup of Figs." With the exceptional facilities, resulting from long experience and entire 
devotion to the one purpose of making our product unequalled, this demand for the perfect laxative 



is met b\J Our fllethod 

•of extracting the laxative properties of Senna without retaining the griping principle found in all other 
preparations or combinations of this drug. This method is known only to us, and all efforts to produce cheap 
imitations or substitutes may result in injury to a physician's reputation, and will give dissatisfaction to the 
patient ; hence, we trust that when physicians recommend or prescribe " Syrup of Figs" (Syr. Fici Cal.) they 
will not permit any substitution. The name "Syrup of Figs" was given to this laxative, not because in 
the process 



of Manufacturing 



a few figs are used, but to distinguish it from all other laxatives, and the United States Courts have decided 
that we have the exclusive right to apply this name to a laxative medicine. The dose of 

"SVRUP OF FIGS" 

-as a laxative is one or two teaspoonfuls given preferably before breakfast or at bed time. From one-half to 
one tablespoonful acts as a purgative, and may be repeated in six hours if .^necessary. 

"Syrup of Figs" is never sold in bulk. It is put up in two sizes to retail at fifty cents and $1.00 pe? 
bottle, and the name " Syrup of Figs " as well as the name of the California Fig Syrup Company is printed o£ 
the wrappers and labels of every bottle. 

CALIFORNIA FIG SYRUP COMPANY 
SAN FRANCISCO, CAL. 
LOUISVILLE, KY. NEW YORK, N. Y. 



THE 

Medical and Surgical 
Reporter. 

No. 1875. PHILADELPHIA, FEBRUARY 4, 1893. Vol. LXVIII— No. 5. 

ORIGINAL ARTICLES. 

OBJECT LESSONS IN GYNECOLOGY. 

W. H. LINK, A. M., M. D, Petersburg, Ind. 
V. PREPARATIONS FOR AN ABDOMINAL SECTION. 



PREPARATION OF THE SURGEON. 

There are a vast number of men in 
country practice who, for reasons best 
known and perfectly justifiable to them- 
selves, have had no special training in ab- 
dominal work. Yet all of these men must at 
times face emergen cies that demand a 
prompt resort to section. There is no 
time to send for a trained operator, for 
ere the message reaches him the patient 
is dead. Then, even if the case is one 
that can wait, the counsel sent for may 
be so busy that he cannot come. There 
is a class of patients who are too poor to 
pay even the attending physician, much less 
some specialist, who has calls enough on 
his generosity at his own door. So the 
emergency patients and the poor must 
put up with the aid near at hand ; and it 
is of prime importance that it be as good 
as circumstances and honest persevering 
effort can bring forth. 

Any country doctor may at a moment's 
notice be called to a case of ectopic preg- 
nancy with rupture, shock, internal hem- 
orrhage and impending death. No time 
to send for the great Herr Professor Doc- 
tor Bock-bier. That belly must be 
opened and cleaned out, and that bleed- 
ing artery tied or a visit from the under- 
taker is the inevitable consequence. 

Again, some child may be suddenly at- 
tacted with agonizing pain in the bowels 
attended with bloody mucoid discharges 



and a sausage-like doughy lump in the 
abdomen on one or the other side. A 
diagnosis of acute intussusception being 
promptly made, if the section is deferred 
till counsel is called from a distance, 
either adhesions will have become so dense, 
or tumefaction of the swallowed gut so 
great, or gangrjene from constriction so 
far advanced, or shock so profound, or all 
of these so combined that when a section 
is resorted to, it will amoun J to no more 
than a autopsy on a living patient. 
Other forms of obstruction, such as vol- 
vulus, concealed hernia and dynamic ob- 
struction from paresis due to appendicitis, 
are equally fatal if treated by procrastina- 
tion. 

In this day and age when fire-arms are 
so plentiful, penetrating wounds of the 
abdomen are not infrequent, while they, 
above all others, brook no delay, and death 
laughs at expectancy. 

A deformed pelvis or a ruptured uterus 
may call upon the medical attendant at 
the most unexpected moment for a Porro, 
and the most hurried preparation will be 
none too rapid if a life is to be saved. 

A fulminant case of peritonitis from a 
leaking or ruptured pus-tube, or ovarian 
scess, may cross the physician's path even 
in the night, and a rapid section with 
irrigation and drainage can alone save the 
patient from immediate dissolution. 

These are not imaginary occurrences 
drawn from a 4 ' grandfather's tales," or 



158 



Original Articles. 



Vol. lxviii 



abstracted from a revolving library ; for 
instances of every case named suppositi- 
tiously have come under my own observa- 
tion — except the ruptured uterus, and I 
have no reason to believe that my practice 
differs from the average practice of 
country doctors in general. If this be the 
general experience why should medical 
journals and medical writers waste so 
much time and space telling us that ab- 
dominal surgery is so intricate and diffi- 
cult that only a chosen few ought to 
tempt fate by resorting to section? Why 
should they not spend more time and 
effort in teaching the benighted country 
doctor the correct principles of abdominal 
surgery ? Why not dwell upon the severe 
techinque that makes work of this kind 
more successful in the hands of the tyro 
than when it is done by men of great ex- 
perience without due attention to every 
detail and compliance with well settled 
principles ? 

Abdominal surgery need not be more 
fatal than any of the major surgical opera- 
tions in the hands of the inexperienced if 
certain well established rules be followed. 
Certainly opening the abdomen and tying 
off a ruptured and bleeding fallopian tube 
does not require any more nerve or skill 
or knowledge of anatomy than to cut for 
stone or to ligate any large artery. Yet 
we are all expected to do these things in 
country practice. The . great difference 
between abdominal and general surgery is 
that any defect in asepsis in abdominal and 
pelvic work is most likely to be attended 
by a large mortality; while in other 
surgery nature is better able to protect 
the patient from the mistakes of the opera- 
tor. But this is no valid objection for 
any man can be clean while soap and water 
are so cheap and abundant. In general 
surgery, too, dirt may be, and often is, 
neutralized by the application of chemical 
antiseptics, which, if used inside the belly, 
would be more detrimental than other or 
accidental kinds of dirt. 

In preparing for a section the first thing 
to consider is the surgeon himself. He 
should be scrupulously clean. The even- 
ing before doing a section he should take 
a bath and change his underwear for fresh 
ones. He should put on clean outside 
clothes, none of which have been worn 
while in attendance upon any septic case, or 
case of erysipelas. When preparing for 
the operation itself he should wear a long 



white apron fresh from the laundry. His 
sleeves should be rolled above the elbows 
and he should scrub his hands and arms 
with a good stiff nail brush, soap and 
water ; the water being as warm as can be 
comfortably borne. This process should 
continue through several changes of water 
and for at least ten minutes. The nails 
being trimmed close should receive very 
careful attention with the brush. The 
brush itself should be sterilized in the 
same way as the sponges, in addition to 
being first thoroughly scalded. After the 
hands of the operator have been thus ren- 
dered aseptic they should not come in 
contact with any substance whatever, ex- 
cept boiled water. If, by accident or 
necessity, the operator should touch any 
object about the room, or any covering of 
the patient, he should at once scrub his 
hands again. 

PREPARATION OF THE INSTRUMENTS. 

The instruments should be put into a 
small shallow pan and, boiling water hav- \ 
ing been poured over them, they should be 
carefully cleaned with a brush and dried 
with a clean towel. The forceps should j 
have all the joints of French locks bored 
out with the point of another forceps cov- 
ered with a towel. Then rinse in hot 
water and carefully dry. Being packed 
away after this process they remain thus 
till taken out for an operation. Then they 
are put into a pan and have boiled water 
poured over them whence they are removed 
as needed. Instruments to be used in ab- 
dominal work should be packed in a special 
bag and never used in any other surgery. 

LIGATURES AND SUTURE MATERIALS. 

Scald the silk or boil it and stretch it 
before threading. Simply scald silk -worm- 
gut. For dressings, in my own work, I 
have always used the gauzes prepared by 
Seabury and Johnson, and I can say that 
I have never had a drop of pus in any 
wound made by my knife and dressed with 
such material. So I have confidence in 
them. 

SPONGES. 

Buy the very best and finest. Never 
use a sponge costing less than twenty-five 
to fifty cents. If properly treated sponges I 
will last a long time and may be used for I 
many operations. Beat and rub them well I 
in order to get out all the sand possible. I 
Then wash through several basins of cold 



February 4, 1893. 



Original Articles. 



159 



water and put in a solution of diluted mu- 
riatic acid over night. In the morning 
wash several times in cold water and drop 
into sulphurous acid (not sulphuric) 2 :10 
and leave twenty-four hours, then wash 
again and drop into absolute alcohol till 
needed. A self-sealing fruit jar makes a 
good receptacle for sponges and is always 
in reach of any one. 

After using sponges wash them in cold 
water; rinse in warm water and drop into 
a basin of a solution of washing soda and 
let stand for six hours. Take out and 
wash and drop into a solution of sulphur- 
ous acid 2:8. After standing twenty- four 
hours wash and drop into alcohol. If the 
operation be on a pus or cancer case one 
had better burn the sponges. 

BRUSHES. 

The nail brushes should be carefully 
washed, then scalded and allowed to stand 
for twenty- four hours in sulphurous acid, 
when they are removed, washed in boiled 
water and dropped into alcohol till needed. 

PREPARATION" OF THE PATIENT. 

The patient should be prepared for the 
operation at least forty-eight hours before- 
hand when possible. She is bathed and 
the hairy parts are thoroughly sham- 
pooed. Her nails are trimmed and care- 
fully cleaned by scrubbing with soap and 
nail-brush. Just before the bath she is 
given a saline and this is repeated in tea- 
spoonful doses every hour until her bowels 
are completely emptied. To assist the ac- 
tion of the saline, after the second dose 
she is given an enema of soap-suds. As 
soon as she is bathed she has clean clothes 
put on and goes to bed. For twenty-four 
hours before the operation all solid food 
must be withheld, and she must have no 
milk at all. Twenty-four hours before 
she is put on the table she is given a bath 
with alcohol and this may be repeated just 
before the operation. She must have a 
vaginal douche three or four times a day. 
Warm water with or without boracic acid, 
as one pleases. Immediately before opera- 
tion her body clothing and the bed clothes 
are all changed for fresh ones. 

After operation she is to have absolutely 
nothing, not even a drink of water for 
twenty-four hours. She may wash out 
her mouth with warm water but must 
spit it out. If she is persistently nauseated 
she may have a half a glass full of hot 



water to be drunk down at once. If 
nausea still continues, and especially if 
vomiting is bilious, she may be given tV or 
\ grain doses of calomel every hour for ten 
or twelve hours. If pain goes beyond ty- 
ing pain give saline and shovel it in till 
catharsis is profuse. Clean the drainage 
tube every half hour at first, then less often 
till it is dry, then remove. 

Drainage tubes for abdominal work 
should be of glass, open at both ends and 
perforated at the lower extremity for a 
distance of one or two inches with very 
fine holes. A very good and cheap syringe 
to suck out the tube with may be im- 
provised by putting a gum catheter on the 
end of a large penis-syringe. Both should 
be new and made aseptic by washing and 
scalding each time before using. The 
strictest asepsis should be maintained 
while empting the drainage tube. 

It is to be remembered that the prime 
factor in abdominal work is cleanliness. 
There must be absolutely no lapse in 
asepsis at any time, by either operator, 
assistants or nurse. To put the hands 
into one's pockets, or to rub the nose, or 
to brush back the hair, or to mop the 
sweat from the brow, is as grave a sin 
against asepsis as one need have his atten- 
tion called to. The hand or finger that 
goes inside the abdominal cavity or that 
touches any of the abdominal viscera must 
come directly from sterilized water only. 



Treatment of Delirium Tremens Wthout 
Chloral, Bromide of Potassium or Opi= 
ates. 

Dr. Norman Kerr, in The Quarterly 
Journal of Inebriety for October, asks "if 
delirium tremens was a morbid state, 
which was the issue of neurasthenia, or 
an effect of alcoholic poisoning. He be- 
lieves it to be the latter, and that the dis- 
ease arose from the cumulative specific 
action of a poison on the cerebral tissue 
through the alcoholization of the blood." 
Acting on this belief, his treatment is to 
eliminate the poison from the brain and 
nervous system, and leaving the healing 
power of nature to do the rest. He avoids 
alcoholic liquors and opiates, chloral, bro- 
mide of potassium and all narcotics. He 
gives as the only medicine liq. am. acet., 
at first every hour in drachm doses, and 
as nourishment, milk, beef juice, broth. 
Coffee was frequently given. 



160 



Original Articles. 



Vol. lxviii 



THE SALIENT POINTS IN APPENDICITIS— ITS DIAGNOSIS AND 

TKEATMENT. 



JOSEPH HOFFMAN, M. D., Philadelphia. 



Eor so hackneyed a subject it were al- 
most necessary to apologize were there 
not so much variance in the views con- 
cerning it by those who, from experience 
or investigation, or both, have dealt with 
it in the light of its pathology as now un- 
derstood — a pathology based upon a scien- 
tifically correct anatomy. Although dem- 
onstrated by Bardleben as early as 1849, 
and by Luschka in 1861, that the caecum, 
and therefore the appendix, is entirely 
within the peritoneal cavity, the fact was 
ignored, and a perverse adherence to tra- 
dition substituted for demonstrated facts 
in all the teaching and discussion concern- 
ing the pathology of this region. Not 
until Mr. Treves, in his Hunterian Lec- 
tures of 1885, insisted upon an anatomy of 
this region now accepted as correct, was 
there serious attention paid to the value of 
surgical interference in a manner calcu- 
lated to impress itself upon the general 
medical understanding, which is even yet 
handicapped by the weight of authority 
slimy with poultices and comatose with 
opium. 

In order to appreciate certain patholog- 
ical peculiarities in the position of the ap- 
pendix after inflammatory complications, 
certain anatomical peculiarities of the 
caecum are not to be overlooked. They 
will satisfactorily explain certain condi- 
tions otherwise puzzling. The caecum 
itself is entirely surrounded by perito- 
neum which, after enclosing it, is reflected 
upon the posterior wall of the abdomen, 
being continuous with the ascending me- 
socolon when this fold exists. The caecum, 
therefore, lies quite free in the abdominal 
cavity and enjoys a considerable amount 
of movement. The appendix is usually 
directed upward and inward behind the 
caecum, coiled upon itself, being retained 
in its position by a fold of peritoneum 
which sometimes forms a mesentery for it. 

The caecum, therefore, hanging more or 
less free in the abdomen, is endowed with 
considerable latitude as to its motion. 
Rokitansky, describes these as threefold, — 
first, rotation upon its own axis; second, 
upon the mesentery as an axis ; and third, 
upon another intestine as an axis. By ro- 



tation upon its long axis the caecum may 
become so twisted that the ileum opens on 
the right side; but when revolving on its 
short axis the appendix mayjbe placed 
toward the anterior abdominal wall, or it 
may be placed at the posterior aspect of 
the intestine. It will be evident that 
when these movements are combined 
there must be a resultant of motion, the 
location of the appendix varying accord- 
ingly as the movement of the caecum. So 
far as the mesentery of the appendix is 
concerned, there is frequently a pouch be- 
tween it and the ileum, consisting of folds 
of peritoneum which, from pressure by 
the rotation of the caecum becomes, either 
congested or atrophied, and is thrown into 
a band or perforates — in either way be- 
coming a source of danger to near-lying 
intestine, either as a strangulating coid, 
or as a ring through which a fold of intes- 
tinft may fall and be choked in a hernial 
fashion. It is evident from these facts, 
that a purely physiological rotation of 
the caecum may bring on a pathological 
congestion without the presence of any 
irritating matter whatever, and hence that 
in simple appendicitis where no concre- 
tion or faecal deposit is found, we are to 
take into consideration such etiological 
factors, and not hastily conclude that the 
adhesions,limited simply by the peritoneal 
coats, have been previously caused by in- 
tra-appendical inflammation or deposit. 
Careful observation of such cases will re- 
duce the number of instances in which an 
appendicitis is supposed to have healed 
by resolution. 

A further point in connection with the 
variable position of the appendix is, that 
although this is variable, it is not abnor- 
mal but depends entirely upon the rota- 
tory movements above referred to. A 
careful consideration of these facts in pri- 
mary operations before there are universal 
adhesions with general pelvic implication, 
will be useful in determining, at least ap- 
proximately, the position of the appendix, 
and so shorten the operation and prevent 
unnecessary handling of the intestines. 
Where operation is subsequent to repeated 
attacks, the anatomy is hopelessly con- 



February 4, 1893. 



Original Articles. 



161 



fused and careful, painstaking effort is 
required to get at the seat of the disease, 
and success is not always then assured. 

Looking at the inflammations in the 
csecal region from a purely anatomical 
standpoint, it is evident that their classifi- 
cation can and should be very much sim- 
plified. In a previous paper I ventured 
to assert that if we are to retain the 
terms perityphlitis, typhlitis and para- 
typhlitis, it should only be to remember 
that they are simply the sequelae to appen- 
dicitis. This, of course, is not to be con- 
strued into a denial of the occurrence of 
stercoral colitis. This lesion is often 
within the range of probabilities, but has 
rarely been demonstrated. Dr. McMur- 
try's case, reported in the Journal of the 
American Medical Association, July 7, 
1888, abundantly proves the real exist- 
ence of perforative capitis, and also shows 
what refined skillful surgery can accom- 
plish in this class of cases. But in deal- 
ing with disease it is facts we want, not 
names, and the nearer we can get down to 
a simple expression of causation, ex- 
pressed in a certain well defined patholog- 
ical exponent, by so much are we closer to 
a correct understanding of the pathological 
processes with which we have to deal. 
Hence, it is here well to consider in gen- 
eral terms that the appendix in real in- 
flammatory conditions of this region, is 
the origin of the trouble, not denying 
that there may be possible exceptions to 
the statement, but arguing rather that 
the exception proves the rule. 

Of late, there has been so much discus- 
sion of the necessity, advantages, time, 
etc. for operation in appendicitis that the 
procedure is itself no longer questioned in 
the so-called suitable cases. Methods, 
lines of incision, after-treatment, and the 
proper selection of cases, at present are re- 
ceiving so much attention, that we must 
before long be placed in a light by which 
the operation can be more intelligently 
appreciated. Apropos of the former 
dilly-dally methods of treatment by opium, 
poultices, and funeral rites of the more 
serious cases, we have two classes of coun- 
sel in regard to operation. The first is 
that at once upon a real danger-signal — 
persistent pain, high temperature, and 
greater or less induration— operation should 
be resorted to. The surgeons of this order 
also advise resort to mild but efficient 
purgation to get rid of all extraneous 



pressure and to relieve congestion. Of 
the other faith are those who counsel 
waiting, with the argument that in reality 
very few cases of appendicitis result fa- 
tally, and that a great majority recover 
under rest and opium. 

A third division now comes to the front, 
with the advice to operate between the at- 
tacks ; in other words to wait for a recur- 
rence before attempting operative relief. 
These latter surgeons really belong to the 
progressive surgeons of to-day. Foremost 
among them beirfg Dr. Senn and Mr. 
Treves. Dr. Senn's argument for opera- 
tion after a primary attack of appendicitis, 
before adhesions are universal or even 
moderate, in the presence of real suppura- 
tion or strongly suspected destructive in- 
flammatory process, is logical from every 
point of view. It stands evident that if 
we are to operate, operation should be done 
before a complexity of adhesions exists 
rendering interference difficult or impossi- 
ble. . Mr. Treves in an article upon the 
treatment of relapsing typhlitis {Brit. Med. 
Journal,. Nov. L889) insists that in such 
cases the best results are obtained by opera- 
ing after all inflammatory and other 
symptoms have ceased. A careful exami- 
nation of the argument of Mr. Treves 
shows that he considers the subject from 
an altogether different standpoint from 
Senn. Dr. Senn would have us operate 
before there are serious inflammatory com- 
plications, and dwells particularly upon 
the safety of such operation. Treves, on 
the other hand, argues for relapsing cases, 
and from his conclusions evidently has in 
mind the worst possible cases. Viewed in 
this light his argument falls short and is 
assailable. If we are to operate, for how 
many recurrences are we to wait ? Then 
again if there is a perforating appendicitis, 
how do we know that the inflammatory 
symptoms will subside at all ? What we 
do know is that the longer the inflamma- 
tory symptoms persist the greater will be 
the complications, and the less will be the 
strength of the patient to endure operation 
if it is finally resorted to. The argument 
of the recurrence of the disease against 
operation by opponents of early opera- 
tion is, I think, used fallaciously. Fitz's 
tables records a recurrence of eleven per 
cent. Those of Kraft, are double this or 
twenty-two per cent. 

From the anatomy of the parts above 
referred to, it is evident that many cases 



162 



Original Articles. 



Vol. lxviii 



of appendicitis are limited to simple in- 
flammatory peritoneal adhesions, and are 
really not appendictis at all, and hence 
have little or no tendency to recur. In 
general statistics, these are all included 
under a general head, when if excluded, 
they will both reduce the number of cases 
of appendicitis, and increase the number 
of recurrences in actual disease. To these 
may also be added cases of stercoral 
caecitis, which are also reckoned as coming 
under the head here discussed, but which 
are really entirely distinct from it. If we 
take out these from the whole number of 
cases, the average of recurrence is still 
further increased. Oases coming under 
these two latter heads, are those which 
most frequently yield to the routine treat- 
ment, and which are therefore put down 
as cured without recurrence. 

In distinguishing these forms from the 
serious or perforating and ulcerative 
varieties of the disease, the treatment has 
much to do. A simple inflammatory con- 
gestion may result in peritoneal adhesions 
and get well without treatment at all. 
This we find constantly in the abdomen. 
A stercoral impaction under opium and 
calomel will finally be relieved, though 
why it will not be relieved by calomel alone 
if relieved by both, is one of the mysteries 
of therapeutics. But if there is a real per- 
forating ulcer what is there curative in 
rest, opium or poultice ? Or what advan- 
tage is there in it, since there is at least 
danger of recurrence in twenty-five per 
cent, of cases, with the danger of perito- 
nitis increased in each recurrence, and the 
need of operation almost imperative if we 
would give the patient any chance ? 
Eecurrent cases must be regarded as the 
typical cases of this disease, and those 
which do not recur, and give no further 
symptoms after prompt depletive meas- 
ures to relieve congestion, as having little 
more relation to them than has roseola to 
scarlatina. That concretions may exist 
in the appendix without giving rise to 
inflammatory trouble does not invalidate 
the general rule that ordinarily they cause 
suppuration. 

But when we have concluded to resort 
to operation what plan are we to pursue ? 
Here we are to be led by the principles of 
abdominal — not of general, surgery. We 
are not for instance to be led by Mr. Treves, 
who falls into the egregious error of con- 
sidering abdominal surgery nothing more 



than general surgery. Treves would have 
us separate all adhesions by the knife, 
just as on the post-mortem table the patho- 
logist secures his specimens. Such advice 
must only come of insufficient observation 
of the work of true abdominal surgeons, 
and from an experience which is too small 
to be generalized. Dr. Homans, of Bos- 
ton, cautions us against the use of the 
drainage tube, saying, ' ' Drainage tubes 
in the abdomen are apt to be followed by 
fistulas" Dr. Homans has not the right 
to condemn the drainage tube ex:cept from 
his own experience. In the hands of many 
the drainage tube has yielded the greatest 
satisfaction, as you have already heard. 
Mr. Tait says it decreases his mortality 
from ten to fifteen per cent. Careful 
cleansing of the tube will prevent the ob- 
jections to its use and free it from an 
odium unmerited. Mr. Treves falls into 
the same error, when he says the drainage 
tube should not be used. In abdominal 
work, no surgeon, whatever his ability, 
can lay down a rule which can remotely 
hope for constant observance so far as 
drainage is concerned. So far as Mr. 
Treves' anatomy is concerned, it is very 
good, the best; so far as his surgery is 
concerned, it is fair to say in many re- 
spects it is very bad from an abdominal 
standpoint. This is especially evident if 
we attempt to follow his directions in 
cases in which we are not able to remove 
the appendix, either from the nature and 
extent of the adhesions or the condition 
of the patient. In the presence of such 
a suppurating, sloughing mass, the only 
thing to do is to open up and get 
down into the suppurating cavity, remove 
all debris possible and introduce a drain- 
age tube to allow the escape of its poison- 
ous contents. 

The differential diagnosis of inflamma- 
tion of the appendix from other diseases 
of the abdomen and pelvis, is not always 
easy. It is more difficult in women than 
in men. Many of the affections however 
that have been confounded with it in diag- 
nosis ought to be excluded by careful ex- 
amination. Such are renal and biliary 
colic, ovarian neuralgia, traumatic rupture 
of the intestine and the like. It is im- 
portant to remember, that in urgent symp- 
toms, positive diagnosis is not called for, 
and that exploratory incision is not only 
justifiable but demanded. 

In men the presence of an indurated 



February 4, 1893. 



Clinical Lectures. 



163 



mass in the right iliac fossa, together with 
the detection of fullness and pain by rectal 
examination, is an important point in 
diagnosis. The right leg is often drawn 
up, and there is tension of the abdominal 
parietes over the csecal region. A chill 
often is a concomitant of perforation and 
peritonitis. Mr. Tait records a case in 
which he diagnosed suppuration at the 
base of the kidney, but which was shown 
by exploratory incision to be a "perityphli- 
tic "^abscess. He says: "The history has 
been most carefully gone into, and even 
now in going over the case, I do not see 
how we could have come to any other con- 
clusion." The differential diagnosis from 
hernia is generally easy, though cases have 
occurred in which the appendix has been 
found in the inguinal canal and scrotum. 
McBurney (V. Y. Med. Jour., Dec. 1889) 
lays especial stress on his observations 
going to prove that the point of the great- 
est tenderness, discoverable by a single 



finger-tip is, in the average aduH, almost 
two inches from the anterior iliac spine, 
on a line from this process to the umbilicus. 
It is not probable that in all cases the 
exact spot of greatest tenderness will be 
even approximately the same, but even if 
in a smaller number of cases it is found to 
correspond, it is to be considered a valu- 
able point in diagnosis. 

The value of puncture in diagnosis of 
appendicitis, to determine the necessity of 
operation from presence of pus, has been 
variously discussed for and against. 
Here difference in opinion stands out 
prominently. But the fact remains that 
if used it can do no good, and when used 
it is only, or should be, when other symp- 
toms point prominently to the pus. If 
puncture is negative, so far as positive evi- 
dence of pus is concerned, it is misleading 
and may do infinite harm. I believe it 
should never be used therefore and should 
be condemned. 



CLINICAL LECTURES. 



PROLAPSE OF THE WOMB FROM HYPERTROPHIC ELONGATION OF 
THE SUPER- VAGINAL PORTION OF THE CERVIX — SUPERNUM- 
ERARY OVARY WITH VENTRAL HERNIA— PYO-SALPIN- 
GITIS— NERVOUS OVARIES.* 



WILLIAM GOODELL, M. D. 



Gentlemen : This patient, forty years 
of age, was married when she was twenty- 
three years of age and has eight children 
— the youngest is eight years old. She 
says her womb comes outside of her body, 
which fact she first noticed eight years 
ago. 

In order to pass her water she is ob- 
liged to get on her hands and knees and 
force the uterine mass back into the 
vagina. Her trouble is due to a prolapse 
of the womb, through hypertrophic elon- 
gation of the supra- vaginal portion of the 
cervix. The bladder is almost wholly out- 
side of her body and that is why she has 
to pass her water in the manner described. 
I have not seen this case before. The 



*Delivered at the Hospital of the University of 
Pennsylvania; reported by Lewis H. Adler, Jr., M. D., 
Late Resident Physician at the Episcopal Hospital 
and the University Hospital. 



doctor who examined her said that the 
uterine measurement was five inches, but 
I do not find it to be over four and a half 
inches. This shows that the uterine tis- 
sue is somewhat elastic, varying in length 
under varying conditions of traction. 
When the mass is outside of the vagina it 
gives a longer measurement than when it 
is pushed back into the vagina. 

Here we have a tumor protruding, the 
ordinary term is prolapse of the womb, 
but it should be designated a prolapse of 
the cervix. The front of this mass is the 
anterior wall of the vagina and the bladder 
is behind it. The posterior wall is also, 
to a certain extent, involved. You see 
that there is a tear of the neck of the 
womb, and this very tear has been prob- 
ably the initial point or cause of her trou- 
ble. Why? The unhealed cervical tear 
caused an irritation which invited blood to 



164 



Clinical Lectures. 



Vol. Lxviii 



the parts. This overnutrition caused 
growth and congestion, and these pro- 
duced weight and traction. Hence the 
cervix was pulled down and with it the 
bladder which is fastened at that part. 
This elongation is covered with a delicate 
epithelium, which is very sore, almost 
raw. 

Here comes the difficult point. We do 
not know whether the bladder began to 
prolapse as the first step in producing the 
condition existing in this case. It is a 
mooted question as to what causes this con- 
dition, whether it is produced by actual 
hypertrophy or by traction. Here is a 
woman who has had a tear of the neck of 
the womb causing cervical hypertrophy. 
When the bladder comes down she is 
obliged to bear down quite forcibly in 
order to pass her urine. This straining, 
aided by the weight of a full bladder, 
elongates the supra- vaginal portion of the 
cervix. We therefore believe this trouble 
here is due to traction. 

Here then we have a vagina turned in- 
side out. The danger in an operation in 
this case is of cutting into the bladder and 
into Douglas' pouch. We have no means 
by which we can measure the extent down- 
ward of the latter. In any event, we 
ought not to get into the bladder. Many 
a gynecologist however has done so. I 
generally pass a sound in the bladder and 
if I do not feel satisfied with the examin- 
ation then I pass in my little finger. I 
have myself cut into Douglas' punch 
but never into the bladder. 

The affection under consideration, 
usually occurs in women who have borne 
children, but sometimes you will find it 
occuring in old virgins, women sixty and 
seventy years of age. In such cases how- 
ever it is not so large. Now the opera- 
tion here would be to amputate the cervix, 
after which the wound would be closed up, 
by what we call "Hager's Spokes of the 
Wheel Suture. " Forcible pressure is made 
by means of this suture and hemorrhage 
is thereby prevented. It will require in 
this case an amputation of one-half an 
inch of the cervix as there will then be 
absorption, by retrograde change, of 
the redundant portion of the womb. We 
have also to perform an operation to re- 
store the torn perineum, which, in its 
present condition, affords no support to 
the internal organs whatever. 

Afterwards she should be able to wear 



a pessary. There are very few women 
with this kind of malady who can wear 
this instrument. With these two opera- 
tions and the subsequent use of Smith's 
pessary, we can, in a measure accomplish 
a cure. In these cases a gynecologist 
cannot promise to cure as he can in other 
operations. There may be a return of the 
disease in time. There is, however, very 
little danger in an operation of this 
nature. 

This woman has just told me that I 
performed an operation on her torn cervix 
three years ago. I had forgotten the fact. 
She says I put thirteen stitches in. This 
operation did not do her any good. She 
was to have come back but never did. 

Sometimes a woman will get pregnant 
and this trouble will return; sometimes 
even without the aid of pregnancy. One 
of the operations advised at the present 
time is to close up the vagina. That pre- 
vents coition. When a woman has not 
borne children and has this trouble, as 
she occasionally will, then in that woman 
the projecting portion of the womb looks 
like the male organ in a state of erection. 
These are cases which require amputation 
of the cervix. I think I have seen only a 
half a dozen of such cases. There is no 
earthly use in putting any kind of a pessary 
into this vagina, unless it is a stem and 
cup pessary. It is sure to come out. 

SUPEENUMEEAEY OVAEY WITH A VEIN- 
TEAL HEENIA. 

The next case is an interesting one of a 
most surprising diagnosis. The patient is 
twenty-eight years of age and has been 
married eight years. She has two chil- 
dren, the youngest four years old. She 
complains of constant pain in the region 
of both ovaries, worse on the left side. It 
passes along the left thigh into the knee- 
joint, showing that there is an ovarian 
nerve involved. She has back-ache and 
frequent vertigo. Her menstrual periods 
continue at regular intervals and last 
four days. According to her statements 
a year and a-half ago a physician operated 
upon her and removed her ovaries. Four 
months after the first operation she had, 
on account of pain and a continuance 
of menstruation, another laparotomy 
performed and the gynecologist said that 
the ovarian tissue had been removed. In 
spite of this her menstrual periods still 
continued. 



February 4, 1893. Clinical Lectures. 



165 



She had two laparotomies performed. 
She asserts this positive!} 7 , yet possibly it 
may have to be taken with some allow- 
ance. Notwithstanding these operations 
she is worse than before. I do not know 
that I shall be able to find the cause of 
her trouble. We have here a very excel- 
lent perineum ; there has been a very trif- 
ling tear of it. You may also notice the 
remains of the hymen. She has had two 
children with no internal tear. It is a 
perplexing case to decide. I did look 
upon it as a case of adhesions of some in- 
testinal loop and I still think such to be 
the case. We will first see whether the 
•womb is movable. I pass in the uterine 
sound. There is a little resistance here 
which may be from the shortening of the 
ligaments by the operations. Now I give 
the sound a sharper curve, so that it will 
be impossible to turn it inside of the 
womb without twisting the womb itself 
on its axis. I find that this organ is in a 
fairly good position — looking a little bit 
to the right — there is no disease here. 
There is no resistance where I press it over 
to the right, so that there is no fixation of 
the organ for it is sufficiently movable. 
Now the next question is, why does she 
menstruate ? That is the puzzle. I do 
not find anything out from this examin- 
ation explaining the continuance of the 
monthlies. 

I shall now make an examination per 
rectum to see if I can discover anything 
there. Yes, there is a body here on the 
right side which ought not to be there. 
It is about the size of an ovary and seems 
to be attached to the womb, as an ovary 
naturally should be. I can give some 
movement to it and it seems slightly cystic. 
But nothing but an exploratory incision 
will tell me what it is. This woman has 
a hernia, as a result of one of her former 
operations, but it can be cured by the op- 
eration I shall perform, if she only gives 
her consent. 

I have told you of the possibility of 
supplementary ovaries, and also that in 
my cases, after a certain length of time, 
the patients all stopped menstruating. 

I shall ask this patient if she will sub- 
mit to an operation and act accordingly. 
Sometimes adhesions to the bowels pro- 
duce a good deal of pain. Here we have 
a movable womb, no adhesions. What the 
body is that I felt per the rectum I am 



not prepared to say ; it feels very much like 
an ovary. 

The operation here would be to perform 
a laparotomy, removing the cicatricial tis- 
sues, which will be found existing in the 
reunited edges of the old incision of the 
operation, and then to bring the freshened 
edges of the abdominal walls together by 
means of silk and catgut sutures. 

PYO-SALPmGITIS. 

Here is a patient twenty-eight years of 
age who has been married eleven years. 
She has had two children, one is seven 
years old and the other eight. She had 
a miscarriage when three months gone 
about five years ago, and has not been well 
since. She has had metrorrhagia for five 
years, that is constant bleeding from the 
womb. She complains of pain in the 
left ovarian region. It is exaggerated by 
walking or by lifting. The symptoms 
look like those of some tubal trouble. She 
has leucorrhcea. One week out of four 
she spends in bed. She is very nervous 
naturally. She is obliged to go to bed 
because she has pain. 

Before this miscarriage which she had 
she received a kick in the abdomen and 
the pains began in three or four days 
afterwards. This injury caused a separa- 
tion of the placenta, and the ovum be- 
came a foreign body. Fortunately her 
womb was not large enough to hold much 
blood or she might have died from in- 
ternal hemorrhage. She says that she 
had an attack of peritonitis after this 
kick, and has occasional attacks even at 
the present time. Yet the case may be 
one merely of nervous ovaries. Some- 
times indeed it is difficult to decide 
whether we have a case of diseased, or of 
nervous ovaries to deal with. 

I find in this case that the womb is 
turned over backwards — a suspicious cir- 
cumstance. On the left side I find an 
enlarged ovary. The womb is badly 
retroverted. When this is the case after 
an attack of peritonitis, in the majority 
of cases, you will find evidences of some 
tubal or ovarian trouble. I pass in this 
uterine sound, and ascertain that the 
womb has impaired mobility. I should 
say that there is extensive disease there, 
but before this can be decided positively 
she will have to be etherized. There is 
probably a pus tube on the left side. I 



166 



Communications. 



Vol. lxviii 



mean by that, a fallopian abscess. She 
had a miscarriage which resulted from 
traumatism — from the kick. The blood 
escaping from underneath the placenta 
became putrid and septicaemia followed. 
The ovary is usually secondarily affected 
by inflammation. If she has pus there it 
explains her history of a good deal of 
groin pain, of trouble with the month- 
lies, difficult locomotion, etc. 

The danger of death in these cases 
from bursting of the tube into the peri- 
ton ial cavity is greatly exaggerated. 

This might happen but it is a very 
rare complication. My advice to this 
patient is to submit to an operation, for 
she will never have another child, the 
ovaries being so diseased that she is 
practically without them. 

NERVOUS OVARIES. 

The last patient I shall show you to- 
day is aged 32 years. She has had five 
children, and has a slight tear of the 
cervix, but not bad enough to need an 
operation. She complains of backache 
and of constant pain in the ovarian region. 
Her menstrual periods are regular, but 
they upset her nervous system. The 
diagnosis in these cases is sometimes very 
perplexing. I get hold of some that 
puzzle me greatly. 

Is this person suffering from the effects 
of a diseased ovary, or has she the affec- 



tion rightly designated as " nervous 
ovaries ?" 

She has symptoms of diseased ovaries 
and yet they may not be organically 
diseased. 

When we find a fixed ovary it is plain 
sailing; but when it is movable, it is often 
puzzling to decide, and many a woman 
has lost perfectly healthy ovaries by such 
counterfeits of organic disease. 

I find that the patient wears a pessary, 
which keeps the womb in perfect position, 
so you can exclude that organ as a cause 
of the pain. She has all the symptoms 
of nervous ovaries. She dreams at night, 
has sleeplessness, nervousness arising from 
family troubles, etc. She has palpitation 
of the heart ; has numbness in her 
hands, and sometimes thinks she is going 
to have paralysis. 

The best treatment then is a preparation 
of bromide of some kind. Ten grains of 
ammonia bromide and five grains of am- 
monia chloride makes a good prescription. 
My Sambul pill is another good remedy. 
Then absolute rest in bed should be en- 
joined for an hour a day at least. No 
one should be allowed to even approach 
her room, if that is possible. Massage 
is most important and if this patient 
were able to pay for such treatment I 
should order her to have a person to rub 
her daily. 



COMMUNICATIONS. 



ABSCESS OF FRONTAL SINUS— REPORT OF CASE— OPERATION.* 



G. A. WALL, M. D., Topeka, Kansas^ 



Cases of abscess of the frontal sinuses 
are certainly. not met with very often, while 
simple catarrhal inflammations of these 
sinuses are of frequent occurrence. It is 
for this reason that I report this case, and 
again the diagnosis and treatment being, 
as a rule, easy, it is well that you should 
know how to take care of a case should 
you meet one, which you are liable to do 
at any time during this season of the year 



* Read before Eastern Kan. Med. Society at Topeka, 
Kansas, Jan. 12, 1893. 

fOcculist and Aurist A. T. and S. F. Hospital Asso- 
ciation. 



when colds are prevalent. The operative- 
procedure is not one so great, but that any 
one with the slightest knowledge of anat- 
omy can do, and .there is little if any risk 
to be taken. 

The literature on this disease is not ex- 
tensive, as most of the authors devote only 
a few paragraphs to it, some none at all. 
Bosworth 1 and Fowler 2 have written 
the most extensively on it. Bosworth's 3 

(1.) Diseases of the Nose and Throat, Vol. 1. 
(2.) Rex. Hand Book, Med. Science. 
(3.) Op. Cit, Page 492. 



February 4, 1893. 



Communications, 



16? 



article is complete and well worth your 
perusal. 

As to the occurrence and causation of 
this disease, permit me to quote from 
some prominent authors. Bosworth says : 
While simple catarrhal inflammation 
ofthe mucous membrane of the frontal 
sinuses occurs in connection with a 
cold in the head more frequently than 
that of any of the other accessory 
sinuses, suppurative inflammation on 
the other hand is one of the rarest oc- 
currences. This is probably due to 
the fact that the infundibulum opens 
from the most dependent portion of 
the cavity thus affording free drainage 
while at the same time it is less liable 
to become occluded." Zukerkandl 
states that he never met with a J single 
instance of uncomplicated disease of the 
frontal sinus. Agnew 4 says he only 
saw one instance where the inflammation 
occurred in the sinuses independent of any 
pre-existing affection of the nasal passage. 
Noys 5 is also of the opinion that this 
disease is consecutive to some nasal trou- 
ble, for he says: "It is necessary in all 
these cases to examine the nasal cavities 
and sometimes the cause will be found in 
hyperthophy of the middle turbinated 
bone." 

The disease may arise as the result of 
any condition causing occlusion of the 
orifice of the sinus or from any obstruc- 
tion in the nasal passage, but Bosworth 
says that from these causes it is exceed- 
ingly rare. He thinks that the most ac- 
tive agents in its causation are traumatism, 
maggots in the nose, gonorrhoea, syphilis, 
scrofula, or the development of tumors 
within the sinus itself. The disease does 
not occur until after puberty, as the 
sinuses are of small size or entirely absent 
during childhood, after which time they 
undergo considerable enlargement from 
recession of the brain. Large frontal 
sinuses do not necessarily imply large 
external prominences over the glabella and 
supercilliary eminences. They are lined 
with mucous membrane which is the con- 
tinuation of that from the middle meatus 
of the nose extending through the in- 
fundibulum. 

The symptoms as given for this 
affection are: Erontal headache, gen- 
ii; Italics are mine. 

(4.) System of Surgery, Vol. III., Page 117. 
(5.) Noyes' Diseases of the Eye, 1890. 



erally intense and increasing as the ac- 
cumulated secretions gather and distend 
the siuus; it is usually persistent although 
it may assume an intermittent type, being 
attended with nausea and vomiting; men- 
tal effort increases it. There will be 
swelling, an erysipelatous blush and 
oedema over the sinuses. There will also 
be rigors and fevers, anorexia and sleep- 
lessness. In my case all these symptoms 
existed ; but in a case reported by Dr. 
Lanphear, the only symptoms present 
were intense frontal headache and fever 
in the earlier stages. 

If the pus accumulation is large and 
the exit obstructed the roof of the orbit 
may be crowded downward so as to pro- 
duce displacement of the eyeball and 
diplopia, and amaurosis ensue. If the 
posterior wall of the sinus is displaced it 
will be indicated by symptoms referable to 
the brain, such as dullness or apathy and 
sleepiness. The brain symptoms are 
usually obscure for the anterior lobes, 
although Otto cites a case where displace- 
ment of the posterior wall of the' sinus 
gave rise to unilateral paralysis. If the 
pus escapes into the brain cavity menigitis 
supervenes. And again, cerebral abscess 
may develope without perforation of the 
bony walls of the sinus. 

The diagnosis will be easy as a rule, the 
symptoms I have given being present in 
part or together. 

The following case came under my ob- 
servation a short time ago : 

On Dec. 28th, 1892, was called to Silver 
Lake, Kansas, in consultation with Dr. 
Dudley to see Mr. L. C, set. 45, a tele- 
grapher, who gave the following history: 
About three weeks ago he " caught cold," 
and the nose seemed to stop up; since 
then he has been having frontal headache, 
which has been increasing in intensity; 
temperature ranging about 101° F., with 
chilly sensations; swelling and oedema 
very great, extending across the forehead, 
especially on side corresponding to the 
affected sinus, down towards the base of 
the nose and into the orbit, at the inner 
canthus. There was an erysipelatous 
blush, and the parts around were very 
painful to the touch. At first sight it 
appeared as if the pus had penetrated the 
orbital plate, but on careful examination, 
no fluctuation could be felt and subse- 
quent events proved that it had not. We 
concluded that we had a case of frontal 



168 



Communications. 



Vol. lxviii 



sinus abscess, and that the only thing to 
do was to open the sinus, which we did in 
the following manner : The patient be- 
ing thoroughly anesthetized, 1 made an 
incision one inch long just above the left 
eye-brow extending almost to the median 
line; the oedema being so great it was 
almost one inch in depth. I was com- 
pelled to make a vertical incision one 
inch long, beginning at the nasal end of 
horizontal cut. I then made use of 
the angle formed by the junction of the 
two incisions as a land-mark for the site 
of my perforation as it was very difficult 
to locate the proper position on account 
of the great oedema. The point of perfora- 
tion being about ^-inch above and internal 
to the inner angle of the orbit. I trephined 
at this point and a great amount of thick 
creamy pus escaped — I should say almost 
an ounce. The wound was then well 
washed out with a weak solution of bi- 
chloride of mercury and dressed with 
bichloride gauze. Owing to the fact 
that we had no drainage tube at hand no 



drainage was used. The operation was 
done at 3 P. M., and the patient rested 
well all the succeeding night. The fol- 
lowing day I saw the patient again and 
found him doing well; temperature nor- 
mal; pulse 72; no more pain or headache, 
and little if any discharge ; swelling and 
oedema decreasing and patient feeling 
very contented. The last report was on 
Jan. 10th, at which time Dr. Dudley 
writes as follows: ''I should regard C.'s 
condition as in every way favorable. 
There is some little discharge daily, prob- 
ably the most of which is serum from the 
external wound. I wash it out with 
1-5000 bichloride solution and follow with 
peroxide of hydrogen full strength. This 
has been the treatment all through the 
case. He has had no symptoms that did 
not indicate a favorable ending. 

" Since the above was written a probe 
has been passed through the infundibulum 
into the nose, thereby establishing a free 
opening into the nose from the sinus." 



AN ATTEMPT TO MAKE A RADICAL CURE IN THREE CASES OF 

HERNIA. 



J. S. WRIGHT, M. D., Brooklyn, N. Y* 



The first case was one of congenital 
hernia of very large size. The second 
case was a large strangulated hernia in a 
healthy sailor thirty-seven years of age. 
The third case was a tightly strangulated 
hernia in a feeble woman fifty years of 
age. 

Case I. November 12th, 1891, I went 
with Dr. Gunther to see W. W., a two- 
year-old boy, who had a very large con- 
genital hernia of the right side. When 
the hernia was fully down it was as large 
as a child's head. It was easy enough to 
reduce it, but it was impossible to keep it 
up. I advised an operation for radical 
cure, even if it did not succeed, for the 
patient's condition could not be more un- 
fortunate than it was. At my request the 
patient was. taken to the College Hospital, 
where I operated December 20th, 1891. 
I operated as if the case were one of 
strangulated hernia. The sac was or- 



*Professor of Operative and Clinical Surgery at the 
Long Island College Hospital, Brooklyn, N. Y. 



ganically continuous with the musculo- 
fibrous structure of the scrotum, and 
after opening it, the large quantity of 
coiled up intestine could not easily be pufc 
back into the abdominal cavity ; the in- 
testine had to be held in, in order to pre- 
vent it from escaping. Then I dissected 
up the entire sac, testicle, spermatic cord, 
and the involved tissues as far as the in- 
ternal ring. Close to the internal ring I 
put a strong cat -gut ligature around the 
neck of the sac and tied it firmly; then I 
cut on 2 the entire sac, as well as the sper- 
matic cord. The cord was atrophied, and 
was continuous with the connective tissue 
of the sac. It would have been quite im- 
possible to close up the sac at its neck, 
without removal of the cord and the testi- 
cle. I closed up the entire wound with 
deep sutures with the intention of ob- 
taining primary union. The soft parts 
were severely injured by the operation, 
and much inflammation followed, making it 
necessary to remove the sutures at an 
early day; yet the wound over the seat of 



February 4, 1893. 



Communications. 



169 



the canal repaired by primary union. 
Four or five days after the operation the 
patient had a severe attack of scarlet 
fever along with other children in the 
same ward. The attack terminated favor- 
ably and did not seem to have any dele- 
terious effect upon the reparative process. 
In the mean time the boy would get out 
of bed and amuse himself playing with 
the other children in the ward. The 
patient was discharged from the hospital 
February 2nd, 1892, apparently with a 
radical cure. 

Case II. W. M., a sailor thirty-seven 
years of age, was admitted to the College 
Hospital, January 25th, 1892, having a 
very large strangulated hernia of the right 
side. A persistent effort to make reduc- 
tion had severely contused the hernial sac 
and its contents. The patient was suffer- 
ing severe pain and the shock was serious. 
The result of an operation was considered 
doubtful. I opened the sac in the usual 
way and found a large quantity of omen- 
tum which had been contused so that it 
contained considerable blood in its folds; 
and the omentum had been twisted into 
several dependent portions. There was a 
small part of the ileum in the sac, but it 
was readily reduced. The spermatic cord 
was dislocated from its usual or normal 
location, and was entangled in the omen- 
tum from the testicle upward to the ab- 
dominal cavity. The protruding omentum 
was quite irreducible, so I ligated it in 
three parts, one of which included the 
spermatic cord ; another ligature was put 
on the spermatic cord just above the 
testicle; then the entire omental mass was 
cut away, and the stump put just inside 
the internal ring. The sac was dissected 
up as close as possible to the peritoneum, 
and the neck of it was tied with a strong 
cat-gut ligature and then cut off. The 
entire wound was closed with deep silk 
sutures. The part in the inguinal canal 
healed by primary union, and the part in 
the scrotum healed by granulation. This 
patient was allowed to get up in about 
five weeks. He went about the ward for 
two or three weeks more, and then began 
to help as orderly; he remained in this 
position for several months, and in the 
mean time seemed to have a complete 
radical cure. 

Case III. A married woman, fifty 
years of age, February 24th, 1892, was 
sent to the College Hospital by her family 



physician. She was suffering from a 
strangulated hernia of the left side. The 
hernia had been down for about three 
days, and had been strangulated about 
twenty-four hours. When I saw her the 
hernia was irreducible, she was suffering 
much pain and the shock was severe. Her 
pulse was feeble and intermittent, and she 
had become indifferent as to the result, 
readily consenting to an operation. When 
I got down to the neck of the sac, I found 
the constriction very narrow, and could 
get under the upper band with much 
difficulty even with a small tenotome. 
When the knuckle of intestine was first 
exposed it looked as if it were gan- 
grenous, but in a few moments the cir- 
culation began to be restored. And so 
confident were we that the strangulated 
intestine would recover that we put it 
back into the abdominal cavity. Then I 
dissected up the sac as far as the internal 
ring, and tied the neck of it with a strong 
cat-gut ligature, and then removed the 
entire sac. The wound of operation was 
closed completely with aseptic silk sutures ; 
I caught the sheath of the femoral canal 
by the suture in order to prevent the 
hernia from escaping in the future. 
Primary union occurred throughout the 
wound; the opening through which the 
hernia came was obliterated, a firm wall 
of resisting material being formed. The 
patient made a good recovery and has 
had no return of the hernia. 

The last case shows the importance of 
removing the sac or, at any rate, of ob- 
literating the neck of the sac so as to re- 
store the continuity of the peritoneum at 
the iutbrnal ring. In the second case the 
testicle had become so much atrophied as 
to be useless, and the spermatic cord had 
become so entangled in the omentum as 
to make it desirable and advisable to re- 
move it, and thus facilitate the obtaining 
of a radical cure. This case only shows 
that the spermatic cord may be removed 
in exceptional cases. In the first case 
there was no visible spermatic cord, and 
the testicle was of the most rudimentary 
nature ; an attempt to save it would have 
failed. 



Hemorrhage from the Stomach or 
Bowels. — Tannic acid, ten to fifteen 
grains, if due to capillary oozing. If from 
typhoid fever or ulcer of the stomach, treat 
as for pulmonary hemorrhage. 



170 



Communications. 



Vol. lxviii 



TWO OASES OF SUPPURATIVE INTRA-PELVIC INFLAMMATION WITH 

SPECIMENS. 



L. S. McMURTRY, M. D., Louisville, Ky. 



Both cases are of long standing salping- 
itis associated with recurring attacks of 
pelvic peritonitis, going on to accumula- 
tions of pus and involving the ovaries and 
adjacent folds of peritoneum in the de- 
structive inflammatory process. 

In the first case you will observe that 
the fallopian tube is as large as the small 
intestine and filled with pus. The ova- 
ries are cystic, a degenerative process often 
associated with long standing inflamma- 
tion in the uterine appendages. This 
photograph shows the firm and universal 
adhesions which fortunately I succeeded 
in detaching without rupture, either of 
the tubes or the cystic ovaries. The patient 
is a young married lady, aged thirty- two, 
and had a history of long standing pelvic 
inflammation; a history formerly familiar 
to the profession under the mistaken and 
erroneous pathological term of "pelvic 
cellulitis." When suppuration occurred 
all the usual symptoms supervened, such as 
fever and sweats. The enucleation of these 
masses from the deep pelvis is rendered 
difficult by the dense adhesions which 
become organized, rendering injury to bowel 
and bladder a frequent complication. If 
removed early in the course of the disease 
the operation is less difficult and less dan- 
gerous. This patient made a good recovery. 

The second case is also one of suppura- 
tive salpingitis and peritonitis of long 
standing ; such a case as is usually desig- 
nated as pelvis abscess. It is the only 
fatal one of a group of abdominal sections 
which I did last week. 

The patient was thirty-four years of 
age; married; never robust and never con- 
ceived. She had undergone various 
methods of local treatment for uterine dis- 
ease and about a year since submitted to 
forcible dilatation of the cervix for dys- 
menorrhea and sterility. Since this time 
she had active intra-pelvic inflammation. 
Seven months ago she became confined to 
her room and bed with symptoms of sup- 
puration. She had high fever with rapid 
pulse and sweating, followed last autumn 
by rupture into the bowel and general 
septic symptoms. The opening into the 
bowel was small and the abscess sac was 
never entirely emptied. It would dis- 
charge for a time, then the opening would 

* Read before the Clinical Society of Louisville. 



close and she would again have fever. I 
saw her in the autumn and advised imme- 
diate operation; the operation was done 
last Thursday. The patient had a feeble 
and rapid pulse and was reduced by pro- 
longed septic fever. 

As can be readily seen from the speci- 
men the operation proved to be of excep- 
tional difficulty. On the right side the 
fallopian tube and ovary were converted 
into a large pus sac, which was as large as 
the fully distended bladder. It was firmly 
attached by organized adhesions to rectum 
and bladder; it seemed continuous with 
both rectum and bladder. Its enuclea- 
tion taxed my digital endurance to the ut- 
most and necessitated great care to avoid 
injury to bladder, bowel and ureters. 
The appendages of the opposite side, as 
can be seen, were extensively diseased — a 
large pyo- salpinx and par- ovarian cyst. 
The operation was thorough, and com- 
pleted in about thirty minutes. The pa- 
tient was put to bed without any apprecia- 
ble shock. Six hours after the operation 
the catheter showed complete suppression 
of urine, and this continued for fourteen 
hours, when the kidneys resumed their 
function. The pulse, however, remained 
high and death occurred from exhaustion 
on the fourth day. 

The condition disclosed by operation in 
these cases is a plea for early interference 
in this class of cases. It is altogether an 
error to suppose that cure can be affected 
in such cases as this either by sponta- 
neous opening into the bowel or by punc- 
ture through the vaginal vault. To ex- 
amine this specimen will satisfy anyone 
upon this point. After discharging the 
sac re-fills, and septic infection and sup- 
puration will go on for years if the 
patient can hold out, and then the cure 
will not be completed. The proper treat- 
ment of these cases, and the only treat- 
ment which can avail, is early and thor- 
ough removal of the suppurating mass 
before the patient is exhausted by pro- 
longed suppuration. When the sac rup- 
tured in the course of the operation in the 
second case reported the pus ran freely 
out on the table and was very offensive. 
The case illustrates the most advanced and 
extreme ravages of inflammation and sup- 
puration within the pelvis. 



February 4, 1893. Society Reports. 



171 



SOCIETY REPORTS. 

THE CLINICAL SOCIETY OF LOUISVILLE. 

Stated Meeting of December 27th, 1892. 



The President, Dr. I. N". Bloom, in 
the chair. 

AMPUTATION AT THE HIP ; RESECTION 
OF THE RIB. 

Dr. A. M. Vance: I simply present 
this patient, boy aged eleven years, to the 
Society to show the result of amputation 
at the hip for suppurative hip-joint dis- 
ease, and resection of the eighth rib for 
effusion in pneumonia. 

The history of the case is about as fol- 
lows: I first saw the patient in Septem- 
ber a year ago and, diagnosticated suppu- 
rative disease of the right hip-joint. As 
is often the case in children of this age, 
the course was rather rapid, an abscess 
forming in Scarpas' space with evidences 
of excessive bone disease. Aspiration 
was practiced several times without any 
great success. In March, 1892, the boy 
was put in the Childrens' Hospital and 
the abscess opened and irrigated. The 
opening was followed by a long season of 
sepsis without any reparative acMon 
whatever going on. At the time the ab- 
scess was opened I discovered that the 
partition of tissue between the femoral 
artery and the abscess cavity was exceed- 
ingly thin, therefore no drainage tube was 
inserted for fear sloughing would take 
place and at the time I prognosticated 
possible rupture of the femoral artery. 

After a month of high fever, excessive 
discharge of pus from the abscess, hectic 
condition, etc., I was called by telephone 
to the Hospital at three o'clock one morn- 
ing, the message being that the patient 
was bleeding profusely. Upon examina- 
tion I found that the femoral 4 artery had 
spontaneously ruptured into the abscess 
sac, the patient being thoroughly exsan- 
guinated. The artery was ligated by 
candle light, and the leg wrapped in cot- 
ton wool and elevated. At the end of 
forty-eight hours the foot was gangrenous 
and, notwithstanding the fact that the 
patient was barely alive — temperature 
104.5° F., pulse beyond counting — ampu- 
tation at the hip was decided upon. 

When the patient was put upon the 



table for operation his pulse was hardly 
perceptible at the wrist, probably about 
170 to the minute. The femur to the 
extent of about four inches was found to 
be very much diseased and the acetabulum 
also being involved. I did not make any 
attempt to clean it, believing that nature 
would do so, my object being to get the 
patient off the table as soon as possible 
owing to his extreme condition. The 
time consumed in operation, from the 
moment anaesthesia was half complete 
until the dressings were applied and the 
patient put in bed, was about nine min- 
utes. Whiskey and nitro -glycerine were 
given hypodermatically after the operation ; 
reaction came on slowly; convalescence 
gradual. There was very little hemor- 
rhage during amputation, the femoral 
having previously been litigated on ac- 
count of rupture. 

About two months after this he was 
taken suddenly sick, and it was founds 
upon examination that he had an attack 
of double pneumonia, both lungs being 
extensively involved. He was still in a 
very hectic condition, having recuperated 
but little from the state of depression at 
which he had arrived, owing to the 
amputation. His case was given up as 
hopeless, all efforts toward helping him 
except to make him as comfortable as 
possible, being discontinued. 

However, the crisis came on the third 
day after the attack, and he slowly began 
to convalesce. His right lung cleared up 
very nicely but the left one remained dull, 
apparently solid. Upon careful examin- 
ation we found that there was an immense 
accumulation of fluid in the left side of 
the chest which was tapped three times; 
at the first aspiration we removed three 
and one-half pints of fluid; the second 
time two pints, and the third time two 
pints, a pint of which was pus. The 
heart at this time was beating way over to 
the right side, showing the extent of the 
effusion. The condition of the patient was 
now equally as alarming as before the 
amputation, and as the aspiration was 
doing no apparent good, I advised that 



172 



Society Reports. 



Vol. lxviii 



another chance be given him and the 
excision of a portion of the eighth rib be 
done. 

This operation was performed about a 
week after the last aspiration, the chest 
being thoroughly washed out with hot 
water and two large drainage tubes in- 
serted. Time consumed in this operation 
was seven minutes. Irrigating the cavity 
of the chest was done in a very thorough 
manner, throwing the water in through 
one tube it came out through the other, 
each inspiration working like a force 
pump. The drainage tubes were allowed 
to remain in about ten days, then removed 
and a pledget of gauze inserted, which 
was also removed in a few days, the wound 
healing perfectly. The patient has en- 
tirely recovered the use of his lung as will 
be observed by deep inspiration, and there 
is bony renewal of the excised portion of 
rib. I think this will be obtained in 
nearly all cases if the precaution is taken, 
as I did in this case, to slit the periosteum, 
turning it back and simply removing the 
rib itself, leaving the periosteum intact. 

I consider this a very remarkable case, 
the patient having gone through two 
grave operations and double pneumonia, 
inside a period of three months. There 
is one thing certain, that without Hos- 
pital advantages, the boy would probably 
have died in either operation. There is 
now no evidence of tuberculous trouble, 
and I think his ultimate recovery is as- 
sured. 

DISCUSSION. 

Dr. W. C. Dugan: I had the pleasure 
of assisting Dr. Vance in the operations 
referred to upon this patient and I consider 
it one of the most remarkable cases on 
record. I also think that a case of this 
kind is extremely rare. Many would not 
have attempted an operation in such ex- 
treme conditions. Kapid surgery saved 
this boy's life. 

Dr. L. S. McMurtry reported two 
cases of "Suppuration Intra-pelvic 
Inflammation, with Specimens." 
(Page 170) 

DISCUSSION. 

Dr. J. M. Krim: If I understood cor- 
rectly, for fourteen hours after the 
operation there was complete suppression 
of the urine. I would like to inquire as to 
the quantity secreted after that time. 

Dr. L. S. McMurtry: There were no 



general symptoms of suppression of urine. 
That the bladder was not injured was 
demonstrated by the fact that the patient 
afterward, without the aid of a catheter, 
passed urine which, of course, could not 
have been done had the bladder been in- 
jured. The suspension of the action of 
the kidneys for some hours after the op- 
eration is significant as showing the im- 
paired nutrition from prolonged septic 
toxaemia. 

Dr. W. H. Wathen: I do not know that 
there is anything I can add to what has 
been said about the first operation. The 
specimens of the second case are interest- 
ing, illustrating two diseases that are occa- 
sionally found co- existing in the pelvic 
cavity; one of inflammatory or septic 
origin, the other (the tumor) the result of 
some unknown cause. Had the case been 
operated upon before the abscess ruptured 
into the rectum the diseased structures 
could have been more easily enucleated 
and removed. But after rupture into the 
bowel, complications arise which make the 
operation difficult and dangerous, and we 
never know the conditions to be treated 
until the abdomen has been opened. Even 
then it is sometimes impossible to know 
the condition of all the structures in the 
pelvis until the operation has been com- 
pleted. 

The reporter stated that the water used 
in irrigation was coming through the 
drainage tube for twenty-four hours after 
the operation. I know of no instance 
where irrigation water remained in the 
peritoneal cavity that long. In cases of 
this character where I have used drainage 
— as my experience widens I drain less, 
but there are cases where you are com- 
pelled to drain — I have noticed that the 
irrigation water did not come through the 
tube or gauze very long after the patient 
was put to bed, but the discharge was of 
serum and blood from the torn structures. 

The largest tubes or tumors are not 
always the most difficult to remove. I 
have removed pus tubes, as large as the 
one exhibited, where enucleation was com- 
paratively easy, and have removed tubes 
much smaller where the enucleation was 
very difficult. I do not understand how 
such tough adhesions could form in such 
a short space of time, and I am sure they 
must have existed before the rapid dicta- 
tion of the uterus. The adhesions of a 
so-called inflammatory exudate and re- 



February 4, 1893. Society Reports. 



173 



cently formed peritoneal adhesions are, 
generally speaking, easily separated. 

Dr. W. C. Dugan : I think the speci- 
men teaches a very valuable lesson — that 
delay is dangerous in such cases. My 
experience Avith pyo-salpinx is that they 
are most all complicated with cystic 
ovaries. To discuss the case further 
would be to repeat what Drs. McMurtry 
and Wathen have stated, as they covered 
the ground. 

LEUCOCYTHEMIA : APPENDICITIS. 

Dr. A. M. Vance : I was called on the 
29th of last November by Dr. Leachman 
to see a boy who had had since last March 
an enlarged spleen. The patient was 
about seventeen years of age and his 
spleen had grown gradually since it was 
first observed in the early part of March 
until the time I saw him, when it was 
enormous. 

I was called to the case to stop hemor- 
rhage from the nose, which had been 
going on for forty-eight hours and the 
boy was pretty well exsanguinated, show- 
ing his grave condition. Dr. Cheatham 
saw the case and the boy was still bleed- 
ing although I had plugged the nose from 
the front and posteriorly. The boy event- 
ually died of hemorrhage from the whole 
alimentary canal. He passed large quan- 
tities of blood per rectum and threw it up 
from the stomach — much more than could 
possibly have come from the nose. Diag- 
nosis had been made as Leucocythemia. 

A post-mortem was obtained and we 
secured the spleen, liver and supra-renal 
capsule. The spleen and liver are exhi- 
bited for your examination. You will 
notice that both organs are enormously 
enlarged, the spleen being over a foot in 
length and weighed when removed nearly 
twelve pounds. The kidneys were also 
very much enlarged. Dr. Louis Frank 
has made several microscopical sections 
of both the liver and the spleen, which I 
have asked him to bring here to-night for 
your inspection, and upon which I hope 
he will give us some further information 
with the result of his repeated tests. 

I was called by Dr. Baker on December 
16th to see a man thirty-two years of age, 
a butcher, who had been suffering for 
twenty-four hours only with all the symp- 
toms of acute appendicitis. He gave the 
history of having had some bowel trouble 



always preceded by diarrhoea, as was also 
this attack, but had never before been 
laid up. The man had a temperature of 
of 103.5° F. when I saw him and had had 
one rigor a few hours before. His pulse 
when Dr. Baker was first called was only 
59 to the minute, and when I saw him, 
despite his fever, it was 72, which is a 
very curious element in the case. I ad- 
vised and performed immediate operation. 

I exhibit here the specimen removed, 
which is a very curious appendix. It was 
on the verge of perforation ; was adherent 
to everything adjacent, and particularly to 
the omentum which had formed a sort of 
wall or sac around it. When I first in- 
troduced my finger and pulled up the ap- 
pendix I thought it was very much 
enlarged. The appendix was tied off at 
the junction with the caecum through 
reasonably good tissue ; all of the omen- 
tum which came in contact with the ap- 
pendix was removed; the wound closed 
with silk worm gut, a glass drainage tube 
being left in twelve hours. The man 
made a rapid recovery. I think if opera- 
tion been delayed twenty-four hours 
longer, he would have had general peri- 
tonitis. 

DISCUSSION. 

Dr. Louis Frank: The exact measure- 
ments of the liver and spleen exhibited 
by Dr. Vance I do not remember, but 
they were much larger at the time of re- 
moval than at present, the liver especially 
having become considerably macerated. 
As yet I have not examined the kidneys 
nor the supra-renal capsule. 

In the spleen, however, T found upon 
microscopic examination what appeared 
to be white infarctions, and with these 
some spots that appeared to be cheesy 
in character, those latter I found in- 
stead of being degenerated tissue were 
made up of dense connective tissue. 
The capillaries and larger vessels of the 
spleen were found to be filled with white 
blood corpuscles and no red ones at all, 
In the several sections made not a single 
red blood corpuscle could be found. In 
the liver there is some increase in the con- 
nective tissue which is due to round cell 
infiltration. Polynucleus cells being also 
found giving a true new connective tissue 
formation, caused probably by ceils that 
had found their way through the thin 
vessels into this connective tissue. Also 
the capillaries between the individual cells 



174 



Society Reports. 



Vol. lxviii 



were very large, these cells being crowded 
to the sides and the capillaries filled in 
with white blood corpuscles. The cells 
in sections of the liver examined had 
undergone no degeneration at all, as we 
might expect to find from pressure, they 
were perfectly norma) cells of the same 
size that we have in ordinary live tissue. 
The liver was rather soft when removed, 
a great deal more so than we expected to 
find. The spleen when removed weighed 
about eleven pounds, the liver a little 
over ten pounds. An examination of the 
blood taken from this patient was made 
by myself, also by Dr. Weidner, some 
weeks before death, and then the pro- 
portion of white to red blood cells was as 
one to two. This is very high, the ordi- 
nary proportion being one to six hundred. 
I have no doubt if the blood had been 
examined just before death the proportion 
would been even more than this. 

DISCUSSION. 

Dr. W. 0. Dugak: I saw the patient 
referred to by Dr. Vance in the latter part 
of February or early in March, and he 
then had a large tumor extending down 
into the pelvis. The question of diagno- 
sis in these cases is one of great impor- 
tance. It is very simple when you 
examine for the notch, which is often- 
times overlooked. The notch in which 
the large vessels enter is always very 
marked and can be easily outlined. When 
this boy came to me the question was 
whether he was suffering from leucocy- 
themia, or whether it was malignant dis- 
ease. I was inclined to the diagnosis of 
leucocythemia and sent him to Dr. Simon 
Flexner ; he being absent from the city at 
the time, his brother made an examination 
of the boy's blood and found the white 
corpuscles one to two. Of course when 
he made this report I decided it was not 
malignant in the sense that we usually 
use the term ''malignant," and refused to 
have anything further to do with the case 
in a surgical way and he went back to his 
physician. 

About a year and a half ago I was called 
by Dr. Larrabee to see a lady in this city 
who had a very large spleen, in fact one 
which nearly filled the abdominal cavity, 
and was asked if I thought it advisable to 
remove it. At first I thought very favor- 
ably of its removal — until I went home — 
then I consulted all the authorities on the 



subject that I had and found that there 
was no case on record that had recovered 
after such operation, and of course, I 
changed my mind. I made a post mortem 
in this case removing the spleen which 
weighed between seventeen arid nineteen 
pounds, if I am not mistaken. In this 
case there was no apparent change in the 
liver or any other organs of the body. 
There are three forms of this disease; one 
form involving the medullary canals of 
the long bones; another involving the 
lymphatics, and the third involving the 
spleen. The pathology of the disease 
remains to be written. Such cases are 
universally fatal, most of them dying as 
did this boy, by hemorrhage. This dis- 
ease is not so rare after all. I know ■ of 
four cases in this city within the last two 
or three years, and doubtless there are 
others. 

Dr. W. H. Wathen: I wish to em- 
phasize the practical value of conservatism 
in the treatment of the case reported by 
Dr. Dugan. Surgery of the spleen has 
been very successful in many particulars 
considering the apparent difficulties with 
which we have to deal. Probably the 
desire to operate upon enlargements of 
this organ has caused men to perform the 
operation where it was contraindicated. 
There are probably very few surgeons en- 
gaged in abdominal work who appreciate 
practically the fact that there is no case, 
at least no well authenticated case, where 
extirpation of the spleen for leucocy- 
themia has been successful. For that 
reason I say this case is especially oppor- 
tune in bringing out this feature so that 
the profession may understand it. 

Dr. J. W. Irwin : I regard these cases 
more in the light of medical curiosities 
than anything else. I have seen two 
cases of this nature within the last twelve 
years. The first was in an adult who lived 
in a malarious part of the country, and it 
was thought for a long time that he had 
an "ague-cake." When the case came 
under my observation, the spleen filled 
nearly the whole of the abdomen, giving 
the appearance of a person in the last 
stages of ascites. Of course the patient 
died and a post mortem was held; the 
spleen was found to weigh twenty- nine 
pounds ; the liver weighed eight pounds. 

The next case which came under my 
observation was in this city less than one 
year ago, in a child under one year of 



February 4, 1893. Society Reports. 



175 



age which was the offspring of healthy 
parents. The child had become so 
"thoroughly anemic that two or three 
physicians had been called and none of 
them would venture a diagnosis. One 
physician said it could not be cured, 
another said he did not know what the dis- 
ease was. I made a careful examination 
and found the spleen very much enlarged, 
with apparently no enlargement of the 
liver. The child was profoundly anaemic 
and died. I am sure that the spleen filled 
three-quarters of the abdominal cavity, it 
was so enormously enlarged, notwithstand- 
ing the tender age. All that I could do 
was to prognosticate death. 

Dr. J. M. Rat: Two years ago last 
September an Irish lad about nineteen 
years old consulted me about his nose. 
He was a great politician and on election 
night had been hit on the bridge of the 
nose. The result was a sinus leading down 
to the septum and on probing I found a 
piece of necrosed bone. By anterior 
rhinoscopy an accumulation of pus was 
found between the bone and periosteum of 
the septum. I made a small incision into 
the pus cavity and let out quite an accumu- 
lation ; hemorrhage was very slight at the 
time. That afternoon I was out and on re- 
turning about 6 o'clock I found the entire 
office floor covered with blood. My serv- 
ant told me that the gentleman whose 
nose 1 cut in the morning had returned 
and his nose had bled so furiously that he 
fainted and a carriage was called to take 
him home. I immediately went to see the 
patient and found him with the most per- 
sistent case of nosebleed that I ever saw. 
I plugged it behind and in frout. Then 
the blood would come out of the sinus. I 
worked with him for three or four hours, 
and at last succeeded in stopping the flow. 
He came to my office again after four or 
five days and I then began to investigate 
the cause of the hemorrhage. He told me 
that at one time he had a tooth extracted 
and had considerable hemorrhage. 

The case then passed from under my 
observation until the following summer. 
In the meantime I understand he remain- 
ed in very good health. The following 
summer he consulted me for intense ver- 
tigo and deafness. In testing his hearing 
the tuning fork pointed to it as of nervous 
origin. He gave me the history that the 
deafness had come on suddenly about a 
week before I saw him. This of course 



put a new aspect upon the case and I began 
to further investigate, still did not make 
a diagnosis. I noticed at this time that 
he did not wear the top button of his 
pantaloons fastened, and upon questioning 
him he said that his abdomen seemed to 
be swollen so that he could not button his 
clothing. I then made an examination of 
the abdomen and found the spleen very 
much enlarged. I was led to make an ex- 
amination of his eyes by the profound 
deafness and enlargement of the abdomen. 
Upon examination with the ophthalmos- 
cope I found a typical illustration of a cut 
in Jaeger's Atlas of Ophthalmology, a pale 
straw colored fundus covered with peculiar 
patches and hemorrhages. Both eyes were 
involved, yet the sight seemed to be per- 
fect. From these symptoms I made the 
diagnosis of leucocythemia. Subsequently 
I believe both Dr. Weidner and Dr. Frank 
examined the blood and pronounced the 
trouble leucocythemia. The man went 
on from bad to worse, growing weaker and 
weaker, and on several occasions had fal- 
len in attacks of vertigo. He came to me 
one day and said he had something on his 
hip that he would like to show me. Upon 
examination I found an immense hema- 
toma, probably as large as your doubled 
fist. In his vertigo he had fallen and said 
this lump appeared on his hip afterwaid. 
This disappeared in a few days and event- 
ually he began to bleed from the gums and 
from the throat. In the meantime his 
abdomen had continued to increase in size 
until he was as large as a woman at the 
ninth month of pregnancy ; distended veins 
running over the abdomen ; his feet also 
became so swollen that he could not walk 
during his last two or three weeks of ill- 
ness. Hemorrhage continued from the 
gums, then from the nose, then he began to 
vomit blood, then purge blood, and finally 
he died. I tried to obtain a post-mortem 
in this case, but was unsuccessful on ac- 
count of objections on the part of his 
family. 

While this patient was coming to me I 
saw in one of the medical journals arsenic 
recommended in cases of this character. 
I prescribed this drug which gave him 
more relief than anything else. He grew 
stronger and seemed to suffer less incon- 
venience from distension of the abdomen 
while under Fowler's solution. 

Dr. L. S. McMurtry: The second spec- 
imen exhibited by Dr. Vance is a very in- 



176 



Society Reports. 



Vol. lxviii 



teresting specimen to me, and the subject 
is one that I do not think has ever been 
thoroughly discussed in the Society. We 
have had several cases reported but I do 
not believe the subject has ever been taken 
up methodically and discussed as it ought 
to be on account of its importance. I re- 
member two years ago this winter I atten- 
ded a meeting of the Surgical Society and 
reported two cases of abdominal section for 
appendicitis, with recovery. In the dis- 
cussion that evening one of the fellows 
implied skepticism as to the existence of 
such a disease and expressed opposition to 
treatment by operative interference. I 
believe at that time there had not been a 
single operation for appendicitis done in 
Louisville. Since that time the operation 
has been done many times in this city ; it 
has been done by Dr. Satterwhite, by Dr. 
Dugan, by Dr. Vance and* by others. It 
is the most common cause of peritonitis in 
the male, and if we will take t: e Health 
Officer's reports as they appear in the daily 
paper every Monday morning, it is the ex- 
ception not to find one, two or three deaths 
reported from peritonitis, which means 
that there was no diagnosis made because 
peritonitis is of itself not a disease. In 
cases of appendicitis we have yet to improve 
in regard to early operation. Now, this 
specimen exhibited tonight had adhesions 
around it, but there was no extensive sup- 
puration, and the operation was done before 
the pulse had run up and before the system 
was saturated with septic products. 

There is one particular fallacy in regard 
to appendicitis that I would like to call 
especial attention to. We often hear the 
argument against operative measures, that 
one case or perhaps a dozen cases has been 
treated by conservative measures,— opium, 
poultices, etc., — and recovered. And one 
case may be reported by five or six different 
physicians as having recovered, which is 
operated upon by the seventh physician. 
This will go on record as six cases of re- 
covery from appendicitis without opera- 
tion when the patient has never recovered 
and has been operated upon by somebody 
else. These statistics are used as an argu- 
ment against operative interference when 
the patients have passed into other hands 
for operation. 

A patient may have recurrent attacks of 
appendicitis and we never know when per- 
foration will occur. I recently operated 
upon a little girl six years old with general 



suppurative peritonitis, where the appen- 
dix had sloughed off and came out with* 
the irrigation water. The operation was 
done on Saturday at eleven o'clock and 
the girl was at school on Wednesday pre- 
ceding. We never know when we have a 
case of this kind and the practical point 
is not only that operative treatment is the 
proper procedure, but we must take one 
step forward and let the surgeon see the 
cases sooner and let the operation be done 
sooner. If it is done early the majority 
will recover. The success of the operation 
in the majority of cases depends upon the 
time elapsing after the initial symptoms 
of the attack, until the operation is per- 
formed. I think: the Society can with ad- 
vantage discuss this very important subject 
and formulate something like definite data 
for operative interference — those symptoms 
which indicate immediate operation. In 
the case reported by Dr. Vance it was 
operated upon right in the golden moment. 
Only to-day a case came under my obser- 
vation where the patient was passing berry 
seeds, etc., through an abscess that had 
broken through the abdominal wall from 
the appendix, indicating how common this 
trouble is and what risks are incurred by 
delay in operating. The operation when 
skillfully performed is not, of itself, dan- 
gerous; whereas delay with uncertain diag- 
nosis is always dangerous in intra-abdomi- 
nal diseases. 

Dr. W. H. Wathe^: This case illus- 
trates the simplicity in operating success- 
fully in some cases of peritonitis of appen- 
dicular origin. The dangers in operations 
of this character with an experienced sur- 
geon are practically nil; but in other 
cases the operation is very difficult, and 
the results are often necessarily fatal be- 
cause of extensive involvment of the peri- 
toneum and abdominal viscera. This is a 
subject that has been discussed and written 
about ad nauseam. Every leading sur- 
geon is practically familiar with the litera- 
ture of the subject; and while there are 
some very beautiful results, the enthusiasm 
of some surgeons has pushed the pendulum 
too far and during the last two years it has 
begun to swing back. The man who does 
not go too far in either direction would 
probably be the safer man for this kind of 
work. Again, it is impossible to always 
tell whether the trouble is appendicular. 
Every surgeon of experience in abdominal 
work has observed cases in his operations 



February 4, 1893. 



Society Reports. 



177 



that have been diagnosticated appendicitis, 
where the appendix was not involved and 
the case was one of peritoneal trouble of 
some other origin. Again, there is no de- 
nying the fact that there are many cases 
where the subjective and objective symp- 
toms plainly indicated appendicitis more 
marked than in many cases operated on, 



where the patients have recovered and are 
now, years after the attack, apparently 
well. I know of several such cases. No 
doubt there are many cases where death 
has resulted because the surgeon had not 
seem them sufficiently early — because of 
delayed operation. On the other hand 
there are cases that are not surgical. 



Cerebral Concussion. 



Miles {Boston Med. and Surg. Jour.) 
reviews the old theories of so-called con- 
cussion of the brain and concludes there 
may be a fatal injury to the head in which 
there is no appreciable gross lesion to the 
brain substance, directly or through its 
membranes. He does not consider the 
old theory of vibration tenable owing to 
the fact that the brain does not exactly 
fill the cavity of the skull ; that there is 
between it and the skull a certain amount 
of cerebro- spinal fluid, and that the mem- 
branes fix the brain so thoroughly in posi- 
tion that any considerable displacement 
would be evidenced by lacerations. Nor 
does he consider that multiple hemor- 
rhages are sufficient to account for the 
many and varied symptoms of concussion. 
He. believes, however, that the symptoms 
are due to a derangement of the cerebral 
-circulation, and he shows by experiments 
on animals that a severe blow on the head 
will cause very marked changes in the 
general circulation. The symptoms, 
therefore, are due to a profound disturb- 
ance of the circulation in the brain pro- 
ducing a condition of anaemia, which is 
due to stimulation of the restiform 
bodies. 

The mechanism of the injury he con- 
siders to be: a blow is dealt to the cranial 
wall ; surrounding the point of impact the 
skull is depressed; following the cone of 
depression from the area into which this 
cone bulges, the cerebro-spinal fluid is 
forcibly expressed at the opposite cone of 
the axis of percussion, forming a cone of 
bulging, which accommodates most of this 
displaced fluid; these cones, however, are 
only of momentary existence, the elasticity 
of the skull permitting the bone to return 
at once to its status quo; at each point, 
therefore, is formed a vacuum the result of 
which is that the blood vessels of the 
membranes and brain substance at this 



place are left for the moment unsupported, 
and rupture. This cone of bulging may 
be regarded as the true contrecoup, but 
Miles is so skeptical as to consider that 
most of the so-called fractures by contre- 
coup are really produced by direct vio- 
lence; the patient, being struck on one 
side of the head, strikes the other side in 
his fall producing a fracture. A blow 
upon the frontal region or vertex will 
naturally produce the cone of bulging 
at the base of the skull and, therefore, 
the fatal cases of concussion are likely to 
be associated with peribulbar lesions. 

By further experiment he finds that a 
sudden aspiration of cerebro-spinal fluid 
leads to extravasation of blood, but slow 
aspiration does not. A hard blow on 
the skull after the blood has been 
so removed gives a much less de- 
structive lesion than when the fluid has 
been left in its normal position. 

He concludes that the phenomenon 
called concussion of the brain is the result 
of a temporary anaemia of that organ ; 
this anaemia is the reflex result of stimu- 
lation of the restiform bodies. These 
are also stimulated by the wave of cerebro- 
spinal fluid, which rushes through the 
aqueduct of Sylvius and the foramen of 
Magendie, and from ' the subarachnoid 
space of the brain to that of the cord, 
when a severe blow is dealt over the skull. 
This wave, in accordance with the laws of 
hydrostatics, would disturb the equilibrium 
of the ultimate nerve cells throughout the 
nervous system. The hemorrhages found 
throughout the brain substances and on 
its surface are to be ascribed to the reces- 
sion of the cerebro-spinal fluid which 
naturally supports the blood-vessels. The 
small hemorrhage found in cases of so- 
called concussion, are rather an index of 
the force producing the injury than the 
cause of the resulting phenomenon. — Abst. 



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Saturday, February 4th, 1893. 



EDITORIAL. 



AN AGNEW MEMORIAL. 



It is difficult for a community., at any 
time, to accept the decree that the work 
of a man like Dr. Agnew is done; that 
for one so loved for his wisdom, the purity 
of his life and unselfish devotion to his 
duty there was not much yet to do, and 
more time alloted to do it in. 

By the right of great powers and many 
virtues, and the beneficent uses made of 
them, Dr. Agnew's memory should be se- 
cured to other generations than that to 
which he belonged. He did too much for 
those among whom he lived and to whom 
he rendered unselfish service, for them, 
without discredit, to fail to build some 
tribute to his memory — something to 
further the great causes to which he de- 
voted all the energies of his mental and 
moral faculties; something typical of his 
noble example, of the purity and courage 
of his life, of his unselfishness to his pro- 
fession and to humanity. 

It is now, while the memory of his 
intense manliness and his effective work 
are warm with us, that steps should be 
taken to provide a memorial to a name 



associated with all that is best in the heal- 
ing art, that will advance the work he 
loved and performed in so masterly a 
manner. Let it be one that will speak 
longer and more fittingly- of him than 
could the most careful and eloquently 
written biography. It should realize 
what he did for the suffering and the 
grateful love they bore him, the expression 
of which can never be carved in marble 
nor traced in bronze. 

There is no more splendid character- 
istic of his life than his unselfish de- 
votion to the welfare of his fellow beings 
without regard to creed, condition or 
social position. He was ever in readiness 
for service. Few men in professional life 
have lived so unselfishly. The profession 
he chose as his life work is one primarily 
of duty. His work was a love, a religion 
which he served with unswerving faithful- 
ness. Through all the busy years of his 
life he kept in it the enthusiasm of youth. 
His chief counsellor was an enlightened 
conscience. 

It requires great courage to be a great 



February 4, 1893. 



Editorial. 



179 



surgeon. He possessed that and more. 
His was not the boldness of greed, nor the 
recklessness of narrow ambition, but the 
fearlessness born of great convictions and 
tender human sympathy. It was a chivalric 
courage that made the timid braver in his 
presence. In his genial, kindly tempera- 
ment, in the variety of his excellencies he 
was the ideal gentleman and physician 
realized. 

His greatness was in disciplined strength 
rather than in specially inherited powers. 
He created his own opportunities and 
wisely made use of them. He may not have 
possessed that indefinable something akin 
to madness, which men call genius, but 
he was the embodiment of intelligent 
power — crowned withal with Christian 
humility and charity. 

He wove his name and work closely into 
the interests and memory of the great com- 
munity he so faithfully and unselfishly 
served. His was a read} 7 sympathy with 
every form of suffering, and was manifes- 
ted by acts rather than by words — the daily 
deeds of one hand unnoted and unknown 
to the other. No taint of insincerity 
marred his character. "He attained to the 
advantage of bringing every man of his ac- 
quaintance into true relation with him. 
No man thought of speaking with him, or 
putting him off with any chat of markets 
or reading rooms. But every man was con- 
strained by so much sincerity to the like 
plain dealing." 

Whatever may be the form of the me- 
morial, those who knew him, one and all, 
will have some honored characteristic to 
recall. Those who were his students — his 
boys, as he was wont to call them — will 
ever preserve a fragrant memory of the 
natural dignity of his thought and de- 
portment, and will treasure the lessons he 
taught with such rare impressiveness and 
rarer modesty. And always they will feel 
the stimulus of his great energy and cour- 
age, and will bear with them some impress 
of his strong personality. 



In all that ethically concerned the pro- 
fession, he had few peers. As an adviser 
he gave of the best he had. A conscien- 
tious consultant, he had no jealousies to 
warp his opinions which were always 
characterized by frankness. 

As a writer he was clear, concise and 
vigorous. Bringing together the knowl- 
edge and experience of all medical science 
he subjected it to the rigid scrutiny of his 
mature judgment and, adding to it much 
of proved value in his own experience, 
gave to the profession by far the best text 
book of modern surgery. His work is 
not that of a mere copyist or translator, 
but has a distinct, strong individuality, 
and will furnish the foundation material 
for many a coming " treatise" on surgery. 

But it is not as an author that Dr. 
Agnew's name will live the longest. The 
marvelous development of medical science, 
in all its departments, must inevitably 
render much of what he wrote obsolete. 
Moreover it is Dr. Agnew — the man, the 
skillful surgeon, the sympathizing friend, 
the helpful counsellor, the modest philan- 
thropist, the unassuming Christian gentle- 
man — whose virtues are to be perpetuated 
in some form worthy of the man. 

The men of other countries, who seek 
home in ours, honor alike the country of 
their birth and that of their adoption, 
when they erect upon our soil memorials 
to the genius of their fatherlands. We 
erect on our public squares costly monu- 
ments in memory of martial spirit and 
martial genius. Why should we forget 
one of the noblest types of American 
private citizenship, who devoted time and 
talent to healing the wounds war made, 
and who spent his unselfish life in en- 
deavoring to relieve the suffering of 
others? 

The establishment, in connection with 
the University Hospital, of a children's ward 
has been suggested as a suitable form of 
memorial to our great surgeon. For var- 
ious reasons this is a fortunate suggestion. 



180 



Translations. 



Vol. lxviii 



For many years Dr. Agnew's name was 
intimately associated with that of the Uni- 
versity of Pennsylvania. There he gained 
laurels for himself and added lustre to the 
fame of the Institution. But most espec- 
ially was it there that the influence of his 
strong personality and clear scientific teach- 
ings made the deepest impression on the 
profession. 

The many thousands of University 
Alumni should see to it that any memorial 
of a friend and teacher so revered, should 
in some measure be adequate to his honor. 
In this form also it would be assured speedy 
accomplishment, and that without undue 
expenditure for sustaining professional 
philanthropists. 

Nor need the movement be confined to 
the Alumni of the University. Hundreds 



of public spirited men, who knew and loved 
Dr. Agnew in life and appreciated the 
stalwart manliness of his character, have 
a common interest and pride in his name 
and fame. It would be their pleasure, and 
duty as well, to aid such a work of love, 
honor and gratitude. 

It is to be sincerely hoped that immediate 
and organized effort will be made by the old 
students and friends of the great surgeon 
and teacher, to erect some fitting tribute 
to his memory — such as will not alone 
honor his name, but be one of the prides of 
our great city. If it be not a children's 
ward or an addition to the University Hos- 
pital, let it be something else worthily rep- 
resentative of the meaning his life and 
work had for his fellow's — wide-reaching in 
the spirit of its benevolence. 



TRANSLATIONS. 

INFECTIOUS ERYTHEMAS, f 



Hutinel has carefully investigated the 
erythemas attendant upon infectious dis- 
eases as occurring in his service at the 
Children's Hospital. The characteristics 
of these cutaneous manifestations studied 
from different clinical points of view, the 
pathological anatomy and the miscro- 
biology are essentially the same, whatever 
may be the primary disease (typhoid 
fever, diphtheria, measles, scarlatina, 
angina, etc.,) and the author has thus 
been enabled to group them into one 
general pathogenic study. The infectious 
erythema may follow in the course, at the 
decline or during the convalescence of the 
preceding disease. Clinically it is 
characterized by macules, or blotches, more 
or less extended, but slightly elevated 
and transient, and having at times a 
marked tendency to become ecchymotic. 
The eruption commences at the wrists, 
the elbows, the knees, the malleoli, on the 
upper part of the buttocks, rarely on the 
neck. It remains at times fixed in these 
points of election, but ordinarily it in- 
vaded the back of the hands and the 

-(-Translated for The Medical and Surgical Re- 
porter, by W. A. N. Dorland, M. D. 



fingers, the fore-arm and arms, the dorsal 
surface of the feet, the front of the legs 
and thighs. The back, breast, and ab- 
domen are more rarely invaded ; the face 
only exceptionally. The progress of the 
eruption is usually centripetal. Its forms 
appertain to the different varieties of poly- 
morphous erythema : linear, circular, . 
papular, measly, scarlatiniform non des- 
quamative, scarlatiniform desquamative 
relapsing. At times purplish spots are 
associated with the polymoi^hous erup- 
tions. In spite of the apparent variability 
of their forms, a variability that depends 
very much ujoon the manner in which the 
skin reacts in the different subjects to the 
irritating agent, these eruptions have com- 
mon characteristics. The different erup- 
tive forms may co-exist, follow each other 
or transform themselves in the same 
patient ; the confluence or the limited 
extent of the eruption does not have any 
connection, slight or great, with the 
gravity of the general phenomena. The 
erythematous patches are generally sym- 
metrical, transient, and disappear with- 
out leaving any trace. They are never 
associated with a similar eruption upon 



February 4, 1893. Translations. 



181 



the mucous membranes; but, on the con- 
trary, often there exist ulcerous lesions 
upon the lips, mouth, pharynx, etc., to 
which Hutinel attributes considerable 
importance as the points of entrance of 
the secondary streptococcic infection 
which becomes the pathogenic cause of 
the infectious erythemas. In typhoid 
fever, in numerous cases otherwise benign, 
Hutinel has witnessed a veritable epidemic 
of infectious erythema, grave and even 
fatal in some cases. The eruption always 
appeared after the second week, either in 
the course of the descending oscillations, 
or after the definite fall of the fever, or at 
a period more or less advanced in con- 
valescence. In measles the frequency 
and the gravity of the eruption appeared 
favored by the atmosphere of the hospital 
and by the coexistence of purulent bron- 
chitis and broncho-pneumonia with strep- 
tococci. The erythema in diphtheria, 
noted by most of the authors, appeared 
more commonly in children than in adults. 
It showed itself either in the beginning of 
the disease, in which case it was generally 
benign ; or at an advanced period, where it 
was much more serious and often fatal. 
In these cases there is almost constantly 
noticed lesions of the lips (fissure, pseudo- 
membranous exudate,) of the mouth, 
(ulcerations, diphtheritic false membrane,) 
of the nose and of the throat (reappear- 
ance of the false membrane with strepto- 
cocci, the specific bacillus of diphtheria 
having often disappeared.) Hutinel also 
noticed secondary infectious erythemas, 
benign or grave, at the close of scarlatina ; 
in the course of certain anginas with 
streptococci (all followed by recovery,); in 
the course of certain choleriform 



diarrhoeas ; in affections of the urinary 
passages ; in intestinal lesions ; in pyogenic 
infections, etc. 

The malignant forms of the in- 
fectious erythema generally accompanied 
grave phenomena ; livid face, pinched 
nose, stupor, emaciation, tendency to 
cyanosis, thermic elevation followed by 
subnormal temperature, then finally by 
hyperpyrexia, slight troubles of the intel- 
lectual functions, profound prostration, 
vomiting, green fetid diarrhoea, scanty 
urine at times albuminous. Certain 
symptoms predominate according to the 
nature of the primary disease: gastro- 
intestinal phenomena, prostration, and 
thermic disturbances in typhoid fever; 
respiratory trouble and broncho-pneumonic 
manifestations in measles; puffing of the 
face, albuminuria, cardiac troubles in 
diphtheria. At the autopsy the liver is 
found enlarged and fatty, the spleen a 
little hypertrophied, Peyer's patches and 
the mesenteric ganglia tumefied, but 
slight renal lesions, and concomitant 
alterations of the respiratory organs com- 
mon to all of the infectious diseases. The 
blood is brownish black, but does not con- 
tain microorganisms. These are not 
found either in the affected skin or in the 
hepatic tissue. There is therefore room to 
admit, in the absence of micro-organisms, 
rather a poisoning of the blood and fluids 
by soluble products, a poisoning com- 
parable to that which plays so important 
a role in diphtheria. The treatment 
should be especially prophylactic ; antisep- 
sis of the mouth, nose, and pharynx, 
isolation of the patient, hospital hygiene, 
etc. (Archiv. gen de med., Paris, Sept. 
and Oct., 1892.) 



CATARRHAL NEPHRITIS IN SYPHILIS, TUBERCULOSIS AND 

LEPROSY (LEPRA). f 



Lancereaux states that these diseases, 
which resemble one another as much in 
their origin as in their anatomical mani- 
festations, may present in the course of 
their evolution three varieties of alteration 
in the kidneys, each having a different 
signification, which it is important not to 
confound. In the first place they directly 

^Translated for the Medical and Surgical Re- 
porter by W. A. N. Dorland, M. D. 



influence these organs and determine in 
them disorders identical with those which 
are produced in the viscera; thus syphilis 
produces in them gummata and a circum- 
scribed interstitial nephritis ; tuberculosis, 
tuberculous lesions en masse starting at 
the Malpighian pyramids, or disseminated 
tubercules; leprosy, the leprous nodosi- 
ties, or a cirrhotic nephritis. 

In the second place, in some cases there 



182 



Translations. 



Vol. lxviii 



follows in an advanced stage of these dis- 
eases, a peculiar degeneration of the ves- 
sels and renal parenchyma designated by 
the name of amyloid, or better leucomatous, 
degeneration. Each of these diseases, 
finally, at some time in the course of its 
evolution gives rise to a nephritis similar 
to the pyretic, and especially to the epithe- 
lial or catarrhal nephritis, which has at 
times been recognized under the name of 
the great white kidney. But these three 
classes of affections, clearly distinct, as 
much by their localization as by their 
clinical manifestations and course, do 
not have the same bond of union with the 
diseases in the course of which they show 
themselves. Those which compose the 
first series, and whose localization is in 
the vessels and the connective-tissue 
stroma, are associated manifestly with the 
general disease, syphilis, leprosy, or tuber- 
culosis. The lesions which make part of 
the second series, very different in nature, 
characterized by a hyaline deposit in the 
tunics of the vessels, belong rather to the 
state of decay of the organism caused by 
the primary disease ; those of the third 
category can no more than these last, be 
under the direct defendance of these dis- 
eases, because of their localization in the 
epithelum, — entirely different from the 
fibro- vascular localization proper to each 
of the diseases in question — their evolu- 
tion and their mode of termination. 

The catarrhal nephritis of syphilis, lep- 
rosy and tuberculosis is similar to the 
nephritis of pregnancy and that of pyr- 
exia in that it is only the indirect effect of 
these diseases ; or rather that it seems to 
find in them the proper elements for its 
development. Unfortunately just what 
these elements are is at present unknown, 
but if a comparison is made between this 
and the nephritis of pyrexia, which has 
the same anatomical localization, it is but 
natural to suppose that they might have a 
similar origin and associate themselves 
with the secretion of toxines created by 
the specific disease. This is a purely 
hypothetical view, it is true, but it does 
not destroy the distinction which has been 
made between the forms of nephritis oc- 
curring in the course of syphilis, leprosy 
and tuberculosis. 

The catarrhal nephritis observed in the 
course of these diseases begins at an early 
period of their evolution, in the first or 
second phase rather than in the last, as 



distinguished from the specific nephritis 
and so-called amyloid degeneration. In 
syphilis, for example, the catarrhal ne- 
phritis shows itself during the secondary 
period, rarely later; and always in tuber- 
culosis and leprosy this affection appears 
before the last stage. 

The onset of this nephritis, usually quite 
abrupt, is manifested, following a fatigue 
or a chilling, by a diminution in the quan- 
tity of the urine and by the appearance 
of an oedema, at first limited to the face, 
scrotum and limbs, but quickly becoming 
general. At the same time is experienced 
a tired feeling; soreness and weight, if 
not pain, in the lumbar region; and, in a 
certain number of cases, a febrile state, 
which may be unrecognized. This group 
of symptoms conduces to an examination 
of the urine, which is small in amount, 
cloudy and colored, of a reddish hue, with 
a specific gravity of 1020 or over, giving 
with nitric acid and heat an albuminous 
precipitate in the form of large flakes of 
a milky whiteness. The deposit, as shown 
by the microscope, is composed of altered 
epithelial cells, hyaline or epithelial casts, 
leucocytes and, more rarely, red globules. 
The swelling of the face and the anasarca 
persist, there is a gradually increasing pallor 
of the skin, the anemia becomes excessive, 
appetite is lost, digestion is disordered, 
sleep is disturbed, there is a loss 
of strength; then in some instances the 
serus extravasations limited to the subcu- 
taneous cellular tissue, invade the pleural, 
peritoneal and pericardial cavities and 
gives rise to dyspnea in proportion to the 
degree of effusion. 

Such are the phenomena which mark 
the first phase of the catarrhal nephritis 
in question. To these are added, at 
the expiration of a variable period of 
time, the symptoms of uremia which 
characterize the second stage. Vom- 
iting now follows immediately after the 
ingestion of food; it is composed in part of 
this and partly of a scanty fluid, grayish 
or slightly greenish in color, and is repeated 
ordinarily several times in the day. It is 
nearly always accompanied by constipation, 
but at times the stools are liquid, whitish 
or greenish, passed readily and without 
acute pain. Under other circumstances 
nervous symptoms make their appearance, 
often grave enough to compromise life. 
There is shortly developed an intense dys- 
pnea, if not a most painful orthopnea, 



February 4, 1893. 



Translations. 



183 



frequently accompanied by severe pains 
which the condition of the thoracic viscera 
will not account for. Insomnia and an 
intense cephalgia of the frontal, temporal 
and occipital regions appear, compared by 
the patients to a compression of the entire 
head similar to the sensation produced by 
a heavy helmet. Convulsive seizures hav- 
ing all of the characteristics of eclampisa, 
and in some cases oft repeated, sap the 
strength of the patient, and delirium and 
coma, more of less profound and danger- 
ous, may be noted. The urine now is less 
abundant and but four or five hundred 
grammes may be passed in the twenty- 
four hours. The proportion of albumin 
is considerable, but the quantity of urea 
and salts is diminished. 

The kidneys under these circumstances 
present alterations scarcely different in 
spite of the diversity of the specific diseases. 
They are tumefied, elongated and swollen; 
their volume may be double the normal. 
Their consistence is soft, at times unctuous, 
and their color sometimes violet and whit- 
ish, sometimes dark-grayish dotted with 
disseminated white spots. The two colors 
show clearly upon the surface of a section ; 
for if the medullary substance is simply 
violet, that of the pyramids presents a 
whitish lardaceous aspect quite distinct. 
Moreover the excretory tubes which con- 
stitute the pyramids, as well as the vessels 
that are distributed to them, are not mod- 
ified; while the secretory tubes, which 
enter into the composition of the cortical 
substance, are always profoundly altered. 
These tubes, in truth, enlarged and dis- 
tended, have their lumen narrowed by the 
tumefied epithelium ; this epithelium is in- 
filtrated by proteid and fatty granulations; 
the cells are deformed, or even reduced to 
fine debris, which together with the hya- 
line cylinders, obstructs the uriniferous 
tubules and places an obstacle to the pas- 
sage of the urine. The glomerular epithe- 
lium is ordinarily less modified. As to 
the vessels and connective tissue stroma, 
they do not present any appreciable abnor- 
mality. 

The diagnosis of this form of catarrhal 
nephritis is generally easy. It is based 
upon the diminution of the urine— its color, 
density and microscopic characteristics and 
also upon the anasarca and most marked 
albuminuria. This nephritis, which most 
writers have confounded with the specific 
nephritis proper to each of the diseases in 



question, is distinguished clearly from the 
latter both by its anatomical localization, 
and by its clinical phenomena. Effectively, 
the essential seat of the alteration is the 
secretory epithelium in one case, the vessels 
and the connective tissue-stroma in the 
other; localizations so different can never 
arise from the same cause. The lesion, al- 
ways partial and asymmetrical in the 
nephritis which depends directly upon 
syphilis, tuberculosis, and leprosy, is general- 
ized and symmetrical in this catarrhal form ; 
the albuminuria is slight and the anasarca 
ordinarily absent in the former, whilst the 
albuminuria is abundant and the anasarca 
considerable in the latter. Thus, none of 
the symptoms proper to these affections 
are similar, and, in consequence, it is not 
possible to confound them, or to attribute 
to them a common origin. It is much 
more difficult to establish a diagnosis be- 
tween this form of catarrhal nephritis and 
amyloid degeneration of the kidneys. 
However, the abundance of the urine, its 
faint color and low density, the absence of 
hyaline casts, are especially characteristic 
of the leucomatous nephritis, and suffice to 
distinguish this affection from the neph- 
ritis in question. 

The prognosis of catarrhal nephritis in 
these subjects is always grave, since to a 
disease very serious in itself is added a con- 
dition which constitutes a true danger. 
The method of combating the symptoms 
of renal inadequacy varies with the stage 
to which the disease has advanced. Early 
in the course dry, or even wet, cups are in- 
dicated over the renal region, together 
with stimulating frictions of the surface 
followed by a hot bath. An exclusive milk 
diet is essential. If these simple measures 
will not suffice, the tincture of cantharides, 
in five or six drop doses may be adminis- 
tered. Should uremic complications ap- 
pear, drastic purgatives are urgently indi- 
cated. While treating this complication 
of the original disease, whether it be sy- 
philis, tuberculosis or leprosy, it is not 
necessary to pursue the specific treatment 
of the primary disease. — Le Bulletin Med- 
ical, Jan. 11, 1892. 

Little Sister — " Mamma says Mr. Nex- 
door is sufferin' from a complication of 
diseases/' 

Little Brother — I guess that's so. I've 
seen three different doctors go in there 
this morning." — Good News. 



184 



Translations. 



Vol. ixviii 



The Treatment of the Pedicle in Ab= 
dominal Hysterectomy.* 

Boulengier mentioned the following 
new methods of operations for Myoma in 
a discussion at the Belgian Gynecological 
and Obstetrical Society. 

1st. The method of Leon Desguin at 
Antwerp, who fastened the integument 
beneath the elastic ligature around the 
stump and holding this in place by the 
pedicle pins, protecting the ends by gauze 
compresses. 

2nd. The treatment of Lauwers of 
Courtrai, who sometimes treats the stump 
extra-peritoneally by applying a ligature 
which remains in situ (24 or 48 hours,) 
until hemorrhage is thoroughly controlled ; 
the ligature is then removed, the stump 
allowed to retract, and the abdominal 
wound closed. He reports three cases 
with rapid recovery. 

3rd. The method of Koufiort of Brus- 
sels, is total extirpation ; he removes the 
stump through the vagina and controls 
hemorrhage by clamps. 

4th. De Baisieux, of Lowen, uses an 
elastic ligature which is united with silk 
threads ; the long end of the silk is al- 
lowed to come out of the lower angle of 
the wound, while the stump is allowed to 
drop back into the abdominal cavity. 
This has been previously covered by iodo- 
form gauze, the end of which is also al- 
lowed to pass out at the lower angle of 
the wound. Two or three days after the 
operation this gauze is removed and re- 
placed by a new piece (up to the second 
week.) After five or six weeks the elastic 
ligature is withdrawn by the silk thread 
which has been allowed to hang out. 
Three operations have been performed in 
this manner with success. — Presse Med. 
Beige, XXIV, 12. 1892. 



Subcutaneous Injection of Fowler's 
Solution.* 

Popow speaks of two cases of malaria 
successfully treated by subcutaneous in- 
jections of Fowler's solution. 

1st. An old man whose history is given 
in detail, and who seemed to be suffering 
from chronic malaria, and in whom the 
treatment with quinine had been unsuc- 
cessful. The condition of the gastro- 
intestinal tract prevented the administra- 



tion of arsenic, so the author concluded 
to try subcutaneous injections of the 
above named solution. The first three 
days there was a dose of 0.4 ccm. of 
the undiluted solution. The following 
three days, the dose given was 0.6 ccm., 
and five days later 0.8 ccm. and then 
three days after 1.0 ccm. Besides this he 
received later for six times 0.8 ccm. and 
twice 1 . ccm. Almost immediately after the 
first few injections a marked improve- 
ment was noticed. The temperature be- 
came normal, the former dyspeptic symp- 
toms disappeared, the liver which had 
been enlarged began to contract, jaundice 
disappeared, as did also the oedema which 
had been present. 

The second case was that of a young 
girl. The diagnosis was made by Professor 
Sacharjin, of masked malaria and chronic 
anaemia. An examination of the blood 
shotved three millions of red blood cor- 
puscles in 1 c. mm., and 75 per cent, of 
haemoglobin. The patient received fif- 
teen injections of the undiluted solution, 
4 times 0.4 ccm., twice 0.5 ccm., 3 times 
0.6 ccm. and 6 times 0.8 ccm. The 
result after this treatment was that the 
violent pains in the head disappeared, the 
enlarged spleen could no longer be de- 
tected by superficial palpitation, and the 
general condition was good. The examin- 
ation of the blood revealed four millions 
of red blood corpuscles in 1 cmm. of 
blood, and 90 per cent, of haemogolobin . 
The patient increased in weight. — Medi- 
zinao IV, 1, pp. 1-5. 1892. 



Contributions to the Total Extirpation 
of Uterus per Vagina in flalig- 
nant Disease.* 

Kossier of Basel, reports a hundred 
cases of carcinoma of the uterus, seen at 
Fehling's Clinic, from June, 1887, to the 
end of 1891. 

Of these, 25 vaginal hysterectomies was 
performed. In two it had to be finished 
by combined laparotomy. After two years 
there were 23.8 per cent, free from return. 
There was but one death among the num- 
ber operated on in which the post mortem 
showed peritonitis and carcinomatous de- 
generation of the retroperitoneal glands. 
E. places great stress upon early diagnosis 
and operation as a means towards a cure. 



^Translated for The Medical and Surgical Re- 
porrer, by Marie B. Werner, M. D. 



^Translated for The Medical and Surgical Re- 
porter, by Marie B. Werner, M. D. 



February 4, 1893. 



Translations. 



185 



Hepatic Insufficiency in Mental Dis- 
eases. — Hepatic Insanity. f 

According to Klippel, among the men- 
tal diseases in which hepatic alterations 
have been observed at the autopsy, or 
during life by the process of modern 
biochemy, one group is formed by the 
affections where the hepatic lesion is 
secondary (sometimes inactive as in gen- 
eral paralysis, sometimes influencing the 
psychical troubles as in alcoholism); 
another group includes those cases in 
which the hepatic lesion is primary and 
appears to provoke the alienation ; this is 
hepatic insanity. The hepatic lesions of 
general paralysis are the nutmeg liver, red 
atrophy, patches of decoloration, fatty 
degeneration, cirrhotic and vaso-paralytic 
congestion (decolorized patches, dilatation 
of the capillaries with hemorrhages, 
diapedesis, cellular compression and cir- 
rhosis). The hepatic lesions of alcohol- 
ism maintain, perhaps, the delirium in 
the cases where this persists notwith- 
standing the suppression of alcohol in 
the cases where the brain is but slightly 
injured. The author has observed a case 
of maniacal excitation slightly resembling 
acute delirium, slightly general paralysis, 
which died in three months without cere- 
bal lesions, but with granulo-atropathic 
degeneration of the liver. He has also 
seen a delirium of chronic evolution with- 
out other lesion than a latent cancer of the 
liver. He compares these facts to the nerv- 
ous manifestations of phosphorous poison- 
ing, and concludes that insanity may follow 
when the liver does not suffice for the elab- 
oration and the destruction of the organic 
substances. — Archives generates de Med., 



Contributions to the Surgery of the 
Gall-bladder.* 

Hermann gives a detailed report of op- 
erations on the gall-bladder done at the 
clinic at Heidelberg. 

Five cases were Oholecystotomy; one a 
bloody dilatation of a pre-existing fistula; 
three ideal Cholecystotomies, three Chole- 
cystenterostomies ; two for extirpation of 
the gall-bladder. The indications for the 
surgical interference in these cases has 
been presented by Czerny in the (Deutsch. 
Med. Wocha. 1892, fto. 23. 

f Translated for The Medical and Surgical Repor- 
ter, by W. A. N. Dorland, M. D. 

* Translated for The Medical and Surgical 
Reporter, by Marie B. Werner, M. D. 



A Contribution to the Study of Fish 
Poisons.* 

Drs. Fischel and Enoch have investi- 
gated this subject and arrived at the fol- 
lowing conclusions. 1st. There exists 
among the fish a bacterial poison. 2nd. 
This in all probability originates from 
spore infection which gains entrance 
through abrasions or wounds. 3rd. The 
symptoms of this infection can be referred 
to the formation of a poison which has 
been propagated in the animal and is an 
albumose. 4th. This is identical with 
that of the bacteria Laprophytic formed 
from Toxalbumose. 5th. The infection 
can be found in some warm blooded ani- 
mals and expresses itself by a paralysis of 
the respiratory and circulatory centers, 
also of paresis of the extremities. 6th. 
The. infection can take place in the intes- 
tinal tract, after large ingestions of this 
poison. 7th. This poison is destroyed by 
boiling. 8th. By improper preparation of 
the fish as food this poison can be assim- 
ilated by the human being and produce 
the symptoms of poisoning. — Fortschs. d. 
Med. X. 8., 1892. 

Auto=suggestion. — The Kitsune=tsuki.f 

The kitsune-tsuki, or possession by 
foxes, is a curious mental affection ob- 
served in Japan and associated with inter- 
nal hallucinations and a double personality. 
Foxes are the object of a superstitious be- 
lief on the part of a large proportion of 
the population, who attribute to them the 
power of assuming the human form ; more- 
over, at times these animals choose the 
body of a living person as their dwelling 
place; the possessed then undergoes a 
veritable doubling of personality ; he hears 
and understands all that the fox says and 
thinks, the latter speaking in a strange 
voice, quite different from the ordinary 
accent of the patient. This disease, ac- 
cording to Baret, appears to be a neuro- 
pathic delirium whose form is explained 
by the special superstitious ideas of the 
country. The treatment should be sug- 
gestive or rather exorcistic. The ex- 
pulsion of the beast leaves the patient 
extremely prostrated, this prostration 
persisting one or two days, after which he 
frequently has lost all conciousness of the 
event. — Jour, d'hyg., September, 1892. 

* Translated for The Medical and Surgical Repor- 
ter, by Marie B. Werner, M. D. 

fTranslated for The Medical and Surgical Re- 
porter, by W. A. N. Dorland, M. D. 



186 



Abstracts. 



Vol. lxviii 



ABSTRACTS. 

OVARIAN DERMOID TUMORS. 



Dr. J. Nigel Stark, reporting a case of 
" Ovarian Dermoid Tumor," says (Edin. 
Med. Jour.), concerning the develop- 
ment of such tumors. 

Dermoids seem more liable to cause pain 
than other kinds of ovarian tumors. 
Probably the visible growth of most 
ovarian dermoids begins at puberty, when 
they participate in the development that 
then occurs in all the pelvic contents, and 
then by their slow, steady enlargement, 
they produce the distressing pressure 
symptoms, — rectal and vesical irritation, 
inflammatory attacks, dysmenorrhea, etc. 

As regards their frequency, Sir Spencer 
Wells says he met with 10 in his first 500 
ovariotomies, and 12 in his second 500. 
J.B. Hunter states that they form between 
3 and 4 per cent, of ovarian cysts. So 
far as I can judge the proportion is about 
2 per cent. 

Dermoids have been described as ' ' cysts 
or tumors furnished with skin or mucous 
membrane (which may or may not be ac- 
companied with the appendages peculiar 
to these structures), occurring in situations 
where skin and mucous membrane are 
not normally found/' These appendages 
may be hair, teeth, bones, sweat-glands, 
sebaceous glands, etc. During the past 
few years much patient study has been be- 
stowed upon dermoids; this cannot be 
wondered at, upon consideration of their 
peculiar structure and mode of formation. 
Doran, in his Tumors of the Ovary, etc. 
(1884), says we can only indulge in spec- 
ulations regarding their origin, but that 
<l the dermoid ovarian question appears to 
be closely and inseparably linked with 
some of the most profound mysteries of 
human life." 

I shall mention very briefly only 
two of the earlier speculations as to 
their origin, as we have now reached some 
definite truths which enable us to form 
what is at least an exceedingly probable 
hypothesis. Eisner's theory was that they 
are all embryonal in their first structure, 
as they occur in places where the epiblast 
dips down to meet the hypoblast, and 
where by processes of grooved involution 
new bodies are formed, first in order be- 
ing the testicle and ovary. Lawson Tait 



says that " the ovum has in it origin buds 
of certain tissues which, under exceptional 
hyperechetic action, may go on to the 
rudimental formation of these tissues 
without a fusion of the male germ." 
Bland Sutton, however, has brought for- 
ward a mass of evidence which demon- 
strates the fancifulness of such explana- 
tions, and proves the true explanation to 
be found in the identity of ovarian folli- 
cles with the acini of glands ; or, putting 
it otherwise, in the fact that the follicles 
are mucous crypts. " Therefore, as the 
membrana granulosa is potentially mucous 
membrane, and as skin and mucous mem- 
brane are convertible structures and mor- 
phologically identical, cysts of the ovary 
containing skin or mucous membrane and 
their appendages are not more remarka- 
ble than cysts and neoplasms occuring in 
connection with other glands." 

The study of the evidence which leads 
to these statements is of deep interest, and 
it is also so full of instruction that I shall 
now endeavor to gather it together in as 
concise a fashion as possible. And, in the 
first place, it is a universally accepted truth 
that skin and mucous membrane possess 
the same structural characters; it is also 
well known that the columnar cells of 
mucous membrane may undergo modifica- 
tion into the stratified cells of epithelium, 
as, to take a common example, in the 
case of hemorrhoids originally internal in 
situation, but which have become external 
to the bowel. In the study of compara- 
tive anatomy we learn that all the usual 
structures of epithelium — pigment, shell, 
hair, sebaceous glands, sweat glands — are 
also existent in the mucous membrane 
of various vertebrates. And, lastly, in 
this connection, the mucous membrane of 
the mouth, pharynx and conjunctiva has 
the same embryological derivation from 
the epiblast as has epidermis. Note also 
that dermoid cysts may contain mucous 
membrane and mucous glands as well as 
epithelium. 

And now we have arrived at the point 
where the question as to the origin of 
ovarian cysts arises; but this confronts us 
with several difficulties, chiefly on account 
of the diversity of opinion given by dis- 



February 4, 1893. 



Abstracts. 



187 



tinguished observers who have made care- 
ful study of the subject. It appears to 
the ordinary reader an impossibility for 
him to form any definite conclusions. So 
far as my own reading and observation 
extend, I have a decided opinion that cysts 
of the ovary nearly always arise from 
changes in the follicles. In a case which 
I carefully examined, the follicles could 
be distinctly seen in every stage of degen- 
eration, and Doran, Sutton, and others 
have narrated similar observations. That 
there may be other modes of origin is 
probable, but still the fact remains that 
most ovarian cysts arise from degenerative 
changes in the follicles. Taking this for 
granted, we now note that each follicle is 
lined by the membrano granulosa, which 
is composed of columnar epithelial cells, 
and secretes the liquor folliculi. Now, an 
ovarian follicle passing through the vari- 
ous stages to become a multilocular cyst 
may retain the simple lining of epithelium 
upon the loculi, or else the epithelium 
may undergo growth ; diverticula are sent 
off, and in this manner the immense num- 
ber of cysts formed. The cells lining 
these cysts are different in appearance to 
those of the membrana granulosa, but, as 
we have seen, it is admitted that epithe- 
lium does change its character according 
to circumstances, and is also readily con- 
vertible into mucous membrane. So far 
the case is pretty evident and capable of 
proof, but now, as Sutton says, " the mys- 
tery up to the present time has been to 
definitely account for the origin of gland- 
ular tissue in such cysts, for it is well 
established that adenomata can only arise 
in connexion with pre-existing glandular 
tissue. " He then goes on to say that as the 
membrana granulosa secretes the liquor 
folliculi, it therefore possesses the func- 
tions of a glandular structure, and that 



we must compare ovarian follicles and 
glands in general, "in order to ascertain 
if any phylogenetic justification exist for 
their extraordinary behavior." The latest 
investigations upon the development of 
ova and ovarian follicles show that the 
cells, which Foulis and others proved to 
be germ epithelial, and from which the 
ova and follicles are derived, are of the 
same nature as those cells which in the 
bowel form the mucous glands. From a 
developmental point of view there is, there- 
fore, evidence of the identity of the ovary 
with a secreting gland, and on morphologi. 
cal grounds this can also be proved. For 
example, the ovary of the frog in the 
breeding season consists of a main cavity 
with numerous diverticula which are lined 
with cells. Some of these cells are larger 
than the others and are really ova. In 
mammals the more complicated structure 
with which we are familiar replaces the 
simple gland as seen in the frog, but 
essentially it is the same, the acini of the 
gland becoming represented by the folli- 
cles. Looking at this question from a 
pathological standpoint, we find the most 
intimate connection between the diseases 
which attack ovarian follicles and those 
sometimes existing in the acini of other 
glands, such as the mammae. Thus, link by 
link, the chain of evidence has been formed 
which leads to belief in the opinion 
that ovarian follicles are identical with 
the acini of glands, or, otherwise, are 
mucous crypts, and, as we have already 
proved and stated, the membrana granu- 
losa is potentially mucous membrane, and 
therefore identical with skin, so that, as 
we previously said, cysts containing skin 
or mucous membrane and their append- 
ages are not more remarkable than cysts 
and neoplasms occurring in connection 
with other glands." 



VIBRATORY MEDICATION. 



Prot. J. M. Charcot, of Paris, (Inter- 
national Medical Magazine) speaking of the 
application of rapid and continuous vibra- 
tions to the treatment of some diseases of 
the nervous system, states: 

"At first the effect of mechanical vibra- 
tion was tried on patients who had hysteria. 
A very large tuning fork was mounted on 
a sounding box and set in motion by a 



bow. This system gave Dr. Vigoroux 
good results in hemianassthsia, and caused 
a certain class of contractions to relax. 
In a case of locomotor ataxia he succeeded 
in relieving the pains by placing his pa- 
tient's legs in the sounding box. In fact, 
a number of experiments, repeated at dif- 
ferent times, showed that the vibrations of 
a large tuning fork have exactly the same 



188 



Abstracts. 



Vol. lxviii 



physiological action as magnetic and static 
electricity. For many years I have learned 
from patients who were attacked by. paral- 
ysis agitans, or Parkinson's disease, that 
they felt mnch better after long trips by 
rail or by carriage. During these journeys 
they get rid of those painful sensations 
they had at home, and this improvement 
persisted for some time afterwards. There- 
fore I have constantly told my students 
that it was possible that some good could 
be obtained in Parkinson's disease by move- 
ments similar to those of a moving wagon 
or a train. 

With this idea in view Dr. Jegu (Dr. 
Charcot's Assistant) aided by M. Solignac 
an engineer, made an arm-chair having a 
special mechanism which causes it to os- 
cillate rapidly on both its anterior and la- 
teral axes. These combined' and varied 
movements produce a trepidation or trem- 
bling that is similar to that felt in a run- 
ning wagon. Dr. Jegu made a number 
of trials with his chair, but dying shortly 
afterwards, Dr. Gilles de la Tourette, a 
former chef de chnique of Dr. Charcot, 
took up these experiments, and up to the 
present has tried them in eight cases, — six 
men and two women. Without making 
any attempt to analyze the very satisfac- 
tory results obtained, we will describe them : 
An amelioration takes place after the fifth 
or sixth sitting : The method is mostly of 
use for the painful sensations in paralysis 
agitans. As soon as the patient gets off 
the "trembling arm -chair" he feels lighter 
and the stiffness is gone. He can walk 
much better, and he is able to sleep at 
night. This last is the most important 
improvement. Except in one case the 
trembling of the patient was not changed. 
This improved state is alwavs felt the day 
of the treatment, so that it should be re- 
peated every day. The results are im- 
portant in this malady where we have so 
far, not been able to find anything to give 
relief. 

Dr. Gilles has had an apparatus con- 
structed which is designed to give intense 
vibrations to the cranium. This apparatus 
is a sort of helmet with separated blades, 
that looks like the "conformator" used by 
hatters to get the shape of the head for 
hats. By a simple device this helmet fits 
any head. It has a plate on top on which 
is placed a small electric motor, moved 
with an ordinary battery. This motor 
gives six hundred revolutions per minute, 



works easily and regularly and produces an 
uniform vibration which is transmitted to 
the cranium. The whole head vibrates 
under it. When the apparatus is in mo- 
tion you hear a soft humming noise which 
should be taken into account in studying 
the results obtained. The number and 
extent of the vibrations can be regulated. 
This "vibrating helmet," put on the head 
of a healthy subject, is well tolerated and 
does not cause any annoyance. In seven 
or eight minutes a sensation of numbness 
is experienced all over the body and the 
person becomes sleepy. Given for ten 
minutes at six p. m., a night of calm sleep 
will follow. Eight or ten sittings cure 
insomnia when not associated with any 
organic brain disease. In three cases it 
was found very efficacious in sick headache 
(migraine.) Three persons having neu- 
rasthenia were treated ; two were cured, 
while the third did not continue the treat- 
ment, although improved. This form of 
vibration acts in neurasthenia by taking 
away, first, the cephalic symptoms, — ver- 
tigo, and the painful frontal constriction 
which is so characteristic of this affection. 
What seems to show that these vibrations 
have a particular action on the brain, is 
that in one case where the spinal symp- 
toms were predominant, the usual weak- 
ness of the inferior members and the sex- 
ual impotence disappeared without having 
to make any vibrations down the spinal 
column. Static electricity had failed in 
this patient. 

It cannot, therefore, be any longer 
doubtful that vibrations of this nature are 
a powerful sedative to the nervous system. 
No definite data are at present offered as 
a number of experiments are to be made, 
but the present statement is made merely 
to show the possibilities opened up by vi- 
bratory medication. 



The largest private medical library in 
the country is said to be that of Dr. Senn. 
It contains about 20,000 volumes. — Ex. 



your 



face so 



Doctor — Ben, what's 
bunged up for ? 

Ben (sadly) — Dat fool George Williams 
done it; I was at de cake walk las' night, 
and all I say to his gal was, " good ebnin, 
Miss Annie, you's lookin' quite pregnant 
dis ebnin.' 7 What make him hit me, 
doctor? 



February 4, 1893. 



Abstracts. 



189 



HYDATIDS OF THE BRAIN. 



Dr. Herbert Barclay (the New Zealand 
Medical Journal) in speaking of "Hyda- 
tids of the Brain" presents a case with the 
following history : A young man aged 20, 
small and stunted in growth, though other- 
wise active and healthy, "was constantly 
among sheep and dogs." When seen for 
the first time, August 7, he complained of 
a headache; his tongue was slightly furred, 
pulse about 70, pupils equal and reacted to 
light. After a few doses of the bromide, 
and 5 grains of calomel, all symptoms disap- 
peared. On August 13, he was in good 
health and spirits, but that night he vom- 
ited, which he attributed to excessive 
smoking. On the evening of the 14th, 
complaining of a severe headache, he passed 
into a dazed condition and died. 

His relatives relate that he sometimes 
said ' 'his head felt as if too full of blood, 
and wished that his nose would bleed." 
Except of the vomiting, already mentioned 
he did not, at any time, complain. But for 
a day or two before he died he had noticed a 
dimness of vision. He had no convulsions. 
After complaining very much of the head- 
ache he became stupid, passed into a state 
of coma, with stertorous breathing, which 
gradually deepened till his death. 

At the post mortem the following con- 
ditions were noted : On opening the skull, 
the dura mater was hyperaemic and the 
superficial cerebral veins were much disten- 
ded. On the under surface of the brain 
was a cystic growth about the size of a 
pigeon's egg and extending into the brain 
tissue for at least half an inch. The 
growth extended from the anterior aspect 
of the pons varolii to the optic commissure 
in front. It was composed of one or two 
cysts, containing clear or brownish fluid ; 
in one part the growth was translucent and 
in another red and opaque. The anterior 
part of the swelling contained a few hard 
particles, apparently chalky concretions. 
The tumor was quite extra- cerebral, and 
careful dissection succeeded in turning it 
completely out of its bed without dis- 
turbing the brain tissue. The brain, 
infundibulum and copora albicanti — the 
parts pressed on by the upward growth of 
the cyst — were almost entirely obliterated. 

This case is interesting for several rea- 
sons. It emphasizes a fact already noted 
(Graham on "Hydatid Disease") that 
symptoms, except headache, may be 



entirely absent. The absence of such 
symptoms as hemiplegia, vomiting and 
convulsions were no doubt due to the situa- 
tion of the growth ; and the absence of visual 
defects was due to the direction in which 
the growth was expanding. The imme- 
diate cause of death was compression of 
the brain from the stoppage of the circula- 
tion, and the giddiness, vomiting and 
gradual loss of eyesight were no doubt due 
to the same causes ; in fact, the condition 
simulated apoplexy, and no doubt had the 
same symptoms occurred in a man of 60 or 
70, a death certificate would have been 
forthcoming. 

The impediment to the venous blood 
flow by pressnre on the sinuses caused the 
distension of the vessels on the brain sur- 
face. The paroxysmal nature of the head- 
ache was evidently due to the over-pressure, 
and as this was relieved by 5 grs. of calomel 
or by a purge, the rapid cure affected is 
readily accounted for. The headache would 
not return till a gradually increasing or 
varying distension became uncomfortable. 
The boy himself, before he died, com- 
plained of feeling his head too full of blood, 
and there is little donbt that venesection 
done early enough would probaly have 
warded off the fatal issue. Graham says 
that blindness is generally a marked symp- 
tom wherever the growth is situated, but in 
this instance — though attached to the op- 
tic tracts — it was never a symptom till the 
case was becoming fatal, and was due, just 
as likely, to pressure on and abolition of 
the function of the occipital lobes as to any 
local pressure on the commissure or tracts. 

The surrounding brain tissue was not 
found condensed, the usual condition when 
hydatids attack other organs, though it is 
occasionally absent. The attempted cure 
by calcification of the cyst is also interest- 
ing, and it seems possible that it might 
have ended in complete recovery. Dr. 
Roberts, of Dunedin, the pathological 
lecturer in the University, examined the 
growth and considered it an inspissated 
hydatid tumor. 

" This machine only registers 250 
pounds, and I weigh in the neighborhood 
of 300." 

"Oh, well, if you want to ascertain 
your exact weight, drop a nickel in twice, 
and foot up the aggregate. " 



190 



Abstracts. 



Vol. lxviii 



THE TREATMENT OF DIABETES MELLITUS BY MEANS OF 
PANCREATIC JUICE. 



In the British Medical Journal for 
January 7th, Dr. Manseil-Jones suggests 
that as the juice of the thyroid gland ap- 
pears to be almost a specific in myxoedema, 
pancreatic juice administered before or 
after meals should be given a fair trial in 
diabetes, as this disease, he adds, in most 
cases, appears to be due to disease or dis- 
ordered function of the pancreas. 

Neither pathology nor physiology, how- 
ever, lend much encouragement to the hope 
that diabetes mellitus will prove tractable 
in such a simple way. In the first place, 
the pathogensis of this disease is much 
more complex than that of myxoedema, 
and diseases of the pancreas account for 
probably only a fraction of the cases of this 
malady. In the second place, even if it 
were a fact, that in most cases diabetes was 
due to disease or disorder of the pancreas, 
the analogy of this doubly-active gland 
both excreting and secreting, with the duct- 
less thyroid gland is not a very close one. 
There is some reason, however, on theo- 
retical grounds, for the belief that pan- 
creatic juice might have some beneficial 
effect even in non-pancreatic diabetes. 

The recent researches into the pathology 
of the pancreatic form of diabetes mellitus, 
of which a most interesting account was 
given by Dr. Vaughan Harley, (Br. Med. 
Jour. Aug. 27th, 1892,) makes it very 
probable that, in addition to the well- 
known tryptic, diostat-splitting and milk- 
curdling ferments, a glycolytic ferment is 
also produced by the pancreas. Assuming 
the existence in the normal pancreas of this 
latter ferment, I thought it possible that the 
administration of a pancreatic extract by 
the mouth might have some beneficial ac- 
tion in diabetes mellitus by assisting to de- 
stroy the sugar in the blood. Acting on 
this idea, therefore, I anticipated Dr. Man- 
sell-Jones's suggestion, and for some time 
past have been treating in a tentative way 
two pronounced cases of diabetes mellitus 
under my care at the Royal Free Hospital, 
by the administration of a liquor pancrea- 
ticus in half -ounce doses given three times 
a day immediately after food. It is the 
generally received opinion that when given 
in this way, the liquor has no appreciable 
digestive power, so that we may put the 
latter effect on one side. No other medi- 



cine was given after this treatment was 
started, and in every respect the patients 
remained under the same condition as be- 
fore. 

In both cases the patients have assured 
me they have experienced benefit from the 
treatment. I should not have attached so 
much importance to their statements had 
it not been that without any suggestion on 
my part or collusion on the part of the 
patients, who attended on different days, 
there was a remarkable agreement in the 
accounts they gave of this beneficial effect. 
They both said they had lost to a great 
extent their feeling of lassitude and lan- 
guor, and felt stronger in every way. 
Their thirst, moreover, had considerably 
lessened, and they had passed a smaller 
quantity of urine. These beneficial effects 
moreover, have continued. The specific 
gravity of the urine and the relative amount 
of sugar have, on the other hand, not been 
affected. 

In an in-patient under the care of my 
colleague, Dr. Samuel West, his house- 
physician, Dr. Rendel, informs me that 
since the administration of liquor pancre- 
aticus, the amount of fluid imbibed during 
the twenty-four hours, which had previ- 
ously averaged 12 pints, has fallen to 6 
pints, with a similar decrease in the amount 
of urine passed. 

In a disease like diabetes we must be 
thankful for even small mercies. For my- 
self I would rather find an improvement 
in the general condition of the patient, in- 
creased strength, diminished thirst, dimin- 
ished quantity of urine as a result of treat- 
ment than a mere diminution of the amount 
of sugar in the urine without such improve- 
ment. I should have preferred of course, 
to have found both results. It is evident 
that liquor pancreaticus is no specific, but 
the effects in these cases are encouraging 
enough to induce me to make further trial 
of it, and it is possible that in cases of 
true pancreatic diabetes the benefit might 
be greater. — Br. Med. Jour. Jan. 14th, 
1893. 



Thermometric Observation. 

"Mamma," said little Johnny, " if I 
swallowed a thermometer would I die by 
degrees." — Exchange. ' 



February 4, 1893. Library Table. 

THE LIBRARY TABLE. 



191 



Traite de Medecine. Charcot. — Bouchard et Brissand. 
Tome III. Paris, G. Masson. 1892. 

In this, the third volume of the " Traite," 
the excellent standard set up by the two pre- 
vious ones is well kept up. The point of 
view of the modern clinician with his views 
of bacteriological infection and his antiseptic 
prophlylaxis and therapeusis is every where 
taken. Even those conservatives who remain 
true to less radical views will find the acute 
and dispassionate discussion of such subjects 
as diphtheria and croup, their relations and 
differences, an excellent example of scientific 
presentation of the facts. The author 
(Ruault) contends for the view, long held in 
France, of the identity of diphtheria and 
croup, contrary to the opinions of Virchow, 
Rokitansky and other German pathologists, 
who, basing their views upon the pathologi- 
cal anatomy of the two affections, regarded 
the one as infectious disease of a gangrenous 
nature and the other as a simply inflamma- 
tory condition. 

As to treatment M. Ruault believes in local 
therapeutics, and seems to think it necessary 
to fight valiantly for this almost unanimously 
held opinion. In speaking of the prophy- 
laxis, a matter of special interest to us at this 
moment in view of this winter's epidemic, 
no suggestion is made of any such ridicu- 
lous plan as the absurd house* quarantine of 
our ingenious Board of Health. Directions 
for the protection by a special covering, such 
as some sort of smock frock, of the clothes of 
these in contact with patient, for the disin- 
fection of all articles in use by boiling water 
or great heat, and for the cleansing of the 
hands by a solution of carbolic acid, which 
Chautemesse and Widal had found the most 
effective against the baccillus of Klebs. As 
an alternative to carbolic acid he recommends 
the acid sulphoricinate of soda, a substance 
of which little is known in this country. 

No word is said of the present favorite 
peroxide of hydrogen, although in all other 
respects the article is well up to its date of 
March, 1892. This practice of dating articles 



pursued throughout the work is, by the way, 
one much to be commended. 

Other subjects treated, and mostly well 
treated in this volume, are diseases of the 
stomach, pancreas, intestines, liver and peri- 
toneum. The latter seems to us the least ade- 
quate, especially in its too scant mention of 
the surgical handling of appendicitis. 



Clinique des Maladies du Systeme Nervenx. M. le 
Professeur Charcot. Paris, 1892. Tome I. 

This volume contains a collection of the 
lectures of Prof. Charcot, and of papers pub- 
lished from his service during the years 1889- 
91, by his various chiefs of clinic and hospital 
internes. 

They are mostly on the more recently de- 
scribed or differentiated forms of nervous 
diseases, but are rather suggestive, as clinical 
lectures should be, than exhaustive. It is a 
pity that the desire of print should have be- 
come so strong as to cause the publication of 
papers so little complete as some of these. In 
the place of the careful, accurate and 
thoughtful work which Charcot's name 
would once have guaranteed, we have a 
series of superficial studies of small impor- 
tance. The most interesting we have found 
are those onr hystero- traumatism, on hys- 
terical oedema, on ophthalmoplegic migraine 
and the remarks in th£ lesson on a case of male 
hysteria upon the frequency of occurrence of 
hysterical troubles in that sex, a frequency 
much greater in Europe than in this country. 
Charcot thinks hysteria major, '*la grande 
hysterie," perhaps even more common among 
men in the lower classes than among women, 
though slight hysterical manifestations affect 
women more than men. The case reported 
had complete lateral facial anaesthesia with 
paralysis of the buccinator and greater zygo- 
matics muscles only ; he had hysterical con- 
vulsions with opisthotonos, a hysterogenetic 
area in the left hypochondrium and sym- 
metrical narrowing of the visual fields — 
certainly a sufficiently curious case. 



CURRENT LITERATURE REVIEWED. 



INTERNATIONAL MEDICAL MAGAZINE. 

The January issue of the International 
Medical Magazine offers eight papers as 
"Original Communications." Five of these 
were read before the American Climatolog- 
ical Association last June. 

Drs. Curtin and Watson, in an article en- 
titled 

The action of Influenza Poison on the 
Heart, and a Study of Influenzal Angina 
Pectoris, 

consider that all treatment lies in finding out 
the cause of the peculiar condition of the 
heart during and following influenza, and as 



as a basis for this inquiry the condition of the 
heart itself. That the heart condition is evi- 
dently not due to anaemia and a consequent 
weakened condition of the heart wall, is 
shown by the rapid onset of symptoms and 
their frequent rapid subsidence. It is not in- 
flammatory, for inflammations of the endo- 
cardium are exceeding rare, and all endocar- 
dial trouble was not prone, during the epi- 
demic, to be aggravated or lighted up afresh, 
and subnormal temperature generally ex- 
isted. Even articular rheumatism associated 
with influenza had little tendency to exo- or 
endo-cardial mischief. In some protracted 



192 



Current Literature. 



Vol. Ixviii 



cases the long-delayed fatal event may have 
been due to nutritional changes in the heart 
muscle, consequent to continued faulty in- 
nervation. 

Under treatment arsenic is recommended 
as valuable in anaemic cases, and one-drop 
doses of Fowler's solution before feeding 
seemed to increase retentive and digestive 
power. Bromide of ammonium quieted rest- 
lessness ; sulphonal generally had a good ef- 
fect, was occasionally dreaded by the patient, 
but generally was the most satisfactory hyp- 
notic, often combined with bromides. Paral- 
dehyde, when well borne, was useful. 

The prognosis was hopeful in almost every 
case no matter how desperate it seemed, ex- 
cept in the aged with organic heart disease, 
cardiac degeneration and senile weakness. 
Recovery was the invariable rule in the 
young and robust. 

Treatment ot the anginal cases differed but 
little from that employed for weak hearts 
from other causes. Excessive and .over-stim- 
ulation of the nerves was to be ever guarded 
against, for it sometimes aggravated the 
symptoms. The quieting effect of rest in 
bed, with the attending protection from cold, 
fatigue and draughts, was of the greatest 
importance in treating the anginose cases. 

"A case of extreme prostration following an 
attack of influenza ; repeated threatened 
heart-failure ; peculiar cardiac irregularity ; 
Recovery" is presented by Dr. Piatt. 

Dr. Robinson's paper 

The value of Conservatism in the treat= 
ment of some common Nasal and Throat 
Diseases especially among Children 

is a plea to the general practitioner to refer 
to the specialist those cases of nasal and 
throat diseases that are so little understood 
by the average practitioner. He takes, as an 
example, a small child from infancy up to 
four or five years of age, who has the " snuf- 
fles " with decidedly obstructed breathing. 
He says " the family physician contents 
himself with prescribing some aconite or nitre 
or perhaps a hot foot-bath," whilst the 
specialist under these conditions, uses one or 
more applications, at suitable intervals, of gla- 
cial acetic acid, or of mono-chloracetic acid, 
by means of a flattened probe wrapped with 
cotton, which will relieve the child's breath- 
ing sufficiently to render further or different 
interference quite unnecessary. The doctor 
takes for granted that the general practition- 
er's knowledge in these cases, is limited to 
the use of internal medication alone. 

Dr. Quimby has quite a lengthy paper on 
" The Pneumatic Cabinet in the Treatment 
of Pulmonary Phthisis." 

Prof. Charcot has a paper on " Vibratory 
Medication ; the Application of Rapid and 
Continuous Vibrations to the Treatment Dis- 
eases of some of the Nervous System," fuller 
mention of which is made elsewhere. 



THE NEW ZEALAND MEDICAL JOURNAL. 

The quarterly issue for October comes to us 
with twelve carefully prepared articles. We 
notice elsewhere the paper of Dr. Barclay, 
"Hydatids of the Brain." 



Dr. Barnett reports a case of "Malignant 
Endocarditis." 
Dr. De Lantour has a 

Case of Twins— Locked Heads 

to offer. The patient was a primipara, aged 
22. After the diagnosis was made and veri- 
fied by Dr. Wait, who did the operating, the 
first child was decapitated and the body de- 
livered. As the " patient seemed to be suf- 
fering from shock and getting weak," a 
craniotomy was performed on the second 
child and it was quickly delivered. Then 
came the difficulty of extracting the loose 
head which had been pushed back to permit 
the other head to come down. After some 
difficulty it was secured by a crotchet and de- 
livered. The patient made an excellent 
recovery without a bad symptom, and has 
had two ordinary pregnancies since. 

The writer has a second paper in this num- 
ber, of interest from the fact of its in- 
frequency. 

A Case of Complete Spontaneous Inversion 
of the Uterus 

following birth. The doctor was in the act 
of delivering the placenta, his left hand 
firmly over the uterus, holding the umbili- 
cal cord loosely in his right hand, and feeling 
the uterus contracting, said, " Bear down, 
and give a little cough " She did bear down 
and gave a tremendous cough. The abdomi- 
nal tumor disappeared and a large mass shot 
out on to the bed extending down almost to 
the knees. This on close inspection proved 
to be not only the placenta, but the uterus, 
fallopian tubes and ligaments. The placenta 
was quickly peeled off, the fundus and body 
of the uterus was bathed with a warm bi- 
chloride of mercury solution — 1 to 1000. 
Treating it like a hernia, gradually applying 
pressure and reduction, the whole mass re- 
turned. There was no hemorrhage or shock ; 
gave brandy, ergotinine and opium ; kept 
her in bed for four weeks. Attended same 
patient in second pregnancy which was quite 
natural ; she recovered without a bad symp- 
tom, and got up on the fourteenth day. 
Dr. Thomas has a paper on 

Constipation 

which he considers under the two heads of 
local and general causes. The local causes 
comprise all those conditions which so act, 
from without or within the large bowel and 
rectum, as to impede the onward movement 
of feces through these parts, either by nar- 
rowing some portion of the canal or by inter- 
fering with its functions, e. g., the pressure 
and irritation of scybala ; putrefactive gas, 
worms, concretions' and tumors of various 
kinds, a weakened condition of the expira- 
tory abdominal muscles as seen in repeated 
pregnancies, and especially after twins, 
obesity, inflammation, lead-poisoning and 
painful affections of abdominal walls, dia- 
phragm or pelvic viscera. The general causes 
are referred to under the heads of tempera- 
ment, habits and errors in diet and dress. 

Dr. Irving presents an article on "Postr 
partum Hemorrhage." 



February 4, 1893. 



Current Literature. 



193 



NEW YORK JOURNAL OF GYNECOLOGY AND 
OBSTETRICS. 

The January number of this journal con- 
tains five papers, two of these — Dr. Potter's 
" Specialism in Medicine, particularly as re- 
lated to Surgery and Gynecology," and Dr, 
Kollock's "Craniotomy on the Living Foetus 
is not Justifiable " appeared in The Medical 
and Surgical Reporter Dec. 3, 1892, as 
part of the transactions of the Southern Sur- 
gical and Gynecological Association. Dr. Ln- 
graham reports three cases of " Ectopic Preg- 
nancy " with the usual history of such cases. 
"The Prevention of Hernia after Incision of 
the Abdominal Walls," is the subject of a 
paper by Dr. Edebohls. 



THE OPHTHALMIC REVIEW 

For November contains an original paper by 
Archibald S. Percival on " The relation of 
Convergence to Accommodation and its Prac- 
tical Bearing." Amongst the reviews is one 
of especial interest: — Galezowski on 

Changes in the Ciliary Circle and the Ex= 
amination of this region in .Constitu- 
tional Affections and in Myopia. 

The Ciliary Circle, which consists of the an- 
terior portion of the retina, the ora serrata 
and the ciliary body, is a region of the eye 
which has not, in the author's opinion, re- 
ceived sufficient attention from ophthalmo- 
scopic observers. This neglect has arisen 
from the difficulty of getting a proper view of 
the region. For the purpose of making the 
examination of the ciliary circle as easy and 
complete as possible, Dr. Galezowski has had 
a lens of short focus joined to a very strong 
prism, which combination he uses, presum- 
ably, with the ophthalmoscope. He states 
that the association of opacity of the anterior 
part of the vitreous with changes in the cili- 
ary circle is so constant, that in making sta- 
tistics of the former, the author found oph- 
thalmoscopic evidence of changes in the cil- 
iary region in 98 per cent. In choroiditis of 
syphilitic origin there is a constant presence 
of atrophic patches at different points of the 
ora serrata. Tuberculous lesions of the ciliary 
circle are recognized as small grey- white ele- 
vations, with surrounding serous infiltrations 
and with pigmentary deposits here and 
there. Gouty effusions are seen in the form 
of sanguineous effusions into the choroid or 
vitreous. 



THE BRISTOL MEDICO-CHIRURGICAL 
JOURNAL. 

For December contains four articles. Dr. 
Skerritt, the President of the Bristol Society 
chose as the subject for his annual address, 

The Teachings of Failure. 

In looking back upon the medical history of 
the past, two episodes stand out in bold re- 
lief before him — one, the history of tubercu- 
lin; the other, the onslaught of influenza. 
The former is a thing of the past; the latter 
he trusts, is so too, and upon neither can we, 
as a scientific, profession, look with satisfac- 
tion. Koch led us away after a will-o'-the 



wisp ; the Influenza did with us what it 
would; and the contemplation of this has 
turned our thoughts towards an aspect of 
work upon which it is good for our mental 
discipline that we should at times meditate. 

Drs. Davy and Blonfield present "Two 
Cases of Locomotor Ataxy with Charcot's 
Joint disease." They point out in presenting 
these cases what M. Charcot has long ago 
called attention to, that the arthropathy is 
an early symptom in locomotor ataxy, and 
that the absence of pain and inflammation is 
a most important point in the diagnosis of 
all diseases of the joint caused by locomotor 
ataxy. 

" Health Resorts in the West of England 
and South Wales " are presented by Dr. 
Brabazon. Dr. Prichard has quite a lengthy 
address on " The early history of the Bristol 
Medical School," which was delivered at the 
formal opening of a new wing of the Univer- 
sity College. 



harper's magazine. 

The first article in the Febiuary Harper's 
is an exposition of Shakespere's "Twelfth 
Night." The illustrations by Edwin Abbey 
are seconded with "comment " by Andrew 
Lang. The pictures are inimitable. The 
poet Whittier is written of, and his haunts 
are beautifully illustrated. Julian Ralph 
writes critically and entertainingly of New 
Orleans, which he calls "Our Southern 
Capital." His eyes see much that is new, 
and Smedly, the artist, helps the reader to 
understand Mr. Ralph's descriptions. The 
most interesting thing in this magazine is 
the powerful and absorbingly interesting 
serial, " The Refugees." Several short 
sketches, the usual poetical efforts and the 
editorial departments make up the balance 
of the magazine. It is a good number. 



THE MEDICAL CHRONICLE 

of Manchester, England, for January con- 
tains a paper by Dr. Thomas Barlow on the 

Prognosis of Chronic Alcoholism in the 
Light of its Pathology. 

The author compares the effect of alcohol 
taken continuously in the system to that pro- 
duced by other poisons, such as lead, mer- 
cury, arsenic, etc. The treatment advocated 
is the absolute withdrawal of the poison and 
the substitution of good food. The idea that 
delirium tremens will follow the cessation of 
the daily dose of alcohol is discussed, the 
author's opinion being that it does not ensue. 
The outlines of chronic alcoholism are well 
presented. 

Dr. E. Stanhope Bishop contributes a 
paper om 

Paradism in Cases of Slight Prolapsus and 
Retroflexio Uteri. 

After reviewing the advantages of and ob- 
jections to Alexander's operation for the 
relief of this condition, the author reports a 
number of cases in which he used faradism 
with good results. One electrode was placed 
in the vagina, pressing against the os uteri, 
whilst the other was applied for a third of 



194 



Periscope. 



Vol. lxviii 



the seance to each great sacro-sciatic notch 
and the back immediately above each pos- 
terior superior iliac spine ; then for one-third 
each to the inguinal canals and external ab- 
dominal rings. He has .treated thirty-two 
cases in this way. Twenty-five of these have 
been satisfactory ; five have failed ; two are 
still under treatment. 

The other papers in this number are : 
" Observations on General Pathology of Can- 
cer—Particularly Cancer of the Breast," by 
Dr. W. Roger Williams. The report of a 
case of "Silent Pneumonia," where there 
were neither breath sounds not adventitious 
sounds over the lower lobe of left lung, by 
Dr. Graham Steele. Dr. D. Lloyd Roberts 
reports "Cases of Ovarian Cystic Tumor,"and 
Dr. T. 1ST. Kelynack a case of " Acute Perfor- 
ative Appendicitis." 

KANSAS MEDIC AiL JOURNAL. 

"Belladonna, with some of its Therapeu- 
•sis," is the title of a paper by Dr. J. E. Minney. 
The various indications for the internal use 
of Belladonna, as well as its use in eye sur- 
gery, are discussed. The paper contains 
nothing new. 

Dr. H. L. Mcllhenny contributes an 
article on 

Pelvic Presentations and their Hanage= 
ment. 

While the article is but a reiteration of the 
well known rules governing these cases it is 
well worth reading, as the author speaks 
from his own experience which has been a 
rich one. He thinks that the troublesome 
condition where the arms go up over the 
head in the pelvis is not of necessity caused 
by traction on the body, as he states that it 
has occurred where no traction has been 
made. Forceps, he thinks, should not be 



applied to the after-coming head unless there 
is a disproportion between the head and the 
pelvis. 

The other articles are " Chronic Tubular 
Nephritis" by Dr. R. E. McVey, and the 
report of a case of "Laryngitis," where 
tra3heotomy [became necessaay owing to 
oedema of the larynx, by Dr. S. C. Pigman., 

THE ANNALS OF GYNECOLOGY AND PEDI- 
ATRY 

for January contains, besides the proceedings 
of the Obstetrical Society of Philadelphia, 
which have already been given in the col- 
umns of this journal, the 

' ' Report of a case of Gastrotomy or Lapa= 
rotomy," 

by Dr. R. E. Haughton. The birth of the pa- 
tient's second child was followed by acute ter- 
minating in chronic suppurative peritonitis. 
At the operation a large suppurating cavity 
was found between the peritoneum and the 
abdominal walls which was incised and 
drained. The peritoneal cavity was not 
opened. Later, a faecal fistula developed, 
communicating with the abscess cavity. 
This healed spontaneously. 

Under Society Proceedings there is a paper 
by Dr. W. W. Potter on "Posture in Rela- 
lion to Obstetrics and Gynecology," with pho- 
tographs of models taken in the various pos- 
tures — horizontal, genu-pectoral, Trendelen- 
berg, etc. That any journal, even that of a 
specialty, would admit this paper suggests 
either a lack of self-respect, a poverty of re- 
source, or a veiled advertising arrangement. 
The aggregation of words affords an ineffi- 
cient setting for the obscene photographs 
displayed, and the excuse offered for the ex- 
hibition of nudity is an insult to the intelli- 
gence of the profession. 



PERISCOPE. 



MEDICINE 

Dr. J. T. Carpenter, Jr., (Philada. Poly- 
clinic) calling attention to severe burns of the 
conjunctiva by the instillation of calomel 
while giving potassium iodide internally, in 
course of his remarks states that the cases 
that came under his notice showed that al- 
though no permanent damage was done, the 
inflammatory reaction was severe and caused 
a muco-purulent conjunctivitis, accompanied 
by chemosis and oedema of the lids with great 
suffering. 

The iodide is excreted by means of the tears 
and when calomel is instilled into the con- 
junctival sac, biniodide of mercury is formed 
which is a severe caustic. It is in a large 
clinical service that this mistake is most likely 
to occur, where, owing to the number of cases 
and the short time in which to treat them, 
inquiries as to what medicine is being taken 
are apt to be neglected, but it may occur in 
one's private practice. Certain it is, that the 
caution is a practical one; do not use calomel 
where iodine or iodides are being admin- 
istered. 



SURGERY. 



Relation of Albuminuria to Surgical 
Operations. 

In a paper upon this important theme, 
read before the Southern Surgical and 
Gynecological Association {Virginia Medi- 
cal Monthly, December, 1891), Dr. Long ar- 
rived at the following conclusions: 

1. Ether or chloroform rarely injures 
healthy kidneys. 

2. When renal disturbances occur from the 
use of an anaesthetic, the kidneys being 
healthy,they are due rather to prolonged nar- 
cosis, exposure of the patient, or perhaps to the 
combined influence of the operation and the 
anaesthetic. 

3. A mild degree of albuminuria (or neph- 
ritis), especially if recent, is not a contra- 
indication of the use of chloroform. 

4. Even in the presence of advanced and 
extensive renal changes, an anaesthetic may 
be employed, provided the patient or the 
family be advised of the additional risk. 

5. Of the two anaesthetics usually employed 



February 4, 1893. 



Periscope. 



195 



it is yet a mooted question as to which is the 
safer, so far as the kidneys are concerned, 
unless it be in obstetrical operations. 

6. While it is by no means the rule, pro- 
found functional disturbance, and even or- 
ganic lesions may be induced by an operation, 
apart from the influence of the anaesthetic. 

7. Such renal changes are due to reflex 
sympathetic action, or to sepsis, or both. 

8. Operations in certain regions— notably, 
the abdominal genito-urinary, anal, or rectal, 
are especially liable to produce renal com- 
plications. 

9. A healthy condition of the kidney 
minimizes, but does not obviate the danger 
referred to. 

10. Albuminuria is always an indication of 
renal lesions, and should be regarded with 
distrust, but is not a positive contraindication 
to an operation. 

11. When albuminuria is associated with 
other evidences of advanced renal changes, 
no operation should be undertaken without 
candidly stating to the patient or friends the 
dangers incident to the condition of the kid- 
neys. 

12. Paradoxical as it may seem, an opera- 
tion will sometimes relieve an albuminuria 
due to acute affections. 

13. No surgeon is justified in undertaking 
an operation without first knowing the state 
of the patient's kidneys. 



Phimosis and Circumcision. 

My observation, experience and mature de- 
liberation have led me to conclude in this 
matter : 

1. That each male child should be exam- 
ined at birth for obstructive phimosis when 
we examine for imperforate anus. 

2. That the prepuce should be retracted 
fully, and all adhesions to the glans broken 
up, all smegma be removed, and the nurse be 
instructed to retract, wash and anoint the 
parts daily for two weeks and once each week 
thereafter. 

3. That a long and redundant foreskin, 
though freely retractable, may be a cause for 
local and reflex diseases, may occasion, or at 
least exaggerate, an undue sexual appetite, 
and so predispose to masturbation, sexual ex- 
cesses, aud ultimately to venereal diseases. 

4. That such cases should be circumcised, 
as should the cases where the foreskin is not 
retractable. 

5. That routine circumcision of all male 
infants is to be condemned. That the pre- 
puce plays an important part in the human 
economy, and should not be amputated ex- 
cept for good and sufficient reasons. 

6. The unhappy experience of the fatal 
case cited, demonstrates that this little opera- 
tion may be attended by grave dangers, and 
should be undertaken with this risk in view, 
and only after we are assured that the 
parents' families are not bleeders. 

7. That infants may endure a copious 
hemorrhage far better than we have hereto- 
fore supposed. — Dr. Wetherill, Univ. Med. 
Mag. 



Laryngeal Intubation. 

Max Scheier gives (Arch, de Laryng., etc., 
November-December, 1892) the experience of 
intubation in the Urban Municipal Hospital 
in Berlin, during what is described as an ex- 
ceptionally severe epidemic of diphtheria. 
The operation was performed in 16 cases of 
acute diphtheria with three recoveries. Of 
the 13 who died all were submitted, subse- 
quently to the intubation, to tracheotomy, 
with the exception of one, a child, aged 4, in 
whom the tube was retained for two days 
and a half, death being due to cardiac paraly- 
sis. The results of subsequent tracheotomy 
were thus very unfortunate ; only one, a case 
enumerated among the recoveries after intu- 
bation survived. Before introducing the 
tube, the mouth, the tonsils, and the uvula 
were swabbed with an antiseptic solution, 
and all membrane thus loosened removed. 
The solution used for this purpose was either 
a 1 per mille solution of thymol, or the follow- 
ing : Salicylic acid 3 parts, boric acid 30 
parts, distilled water 1,000 parts. Among the 
causes of failure of the operation Scheier 
enumerates swelling of the epiglottis and 
ary-epiglottic folds, and he reccommends that 
a laryngoscopic examination should, if possi- 
ble, be made before attempting to introduce 
the tube. Another cause of immediate fail- 
ure is pushing membrane in front of the 
tube into the trachea ; in some of the cases of 
apparent failure the tube when removed 
brings away lalse membrane or a plug of 
mucous, and breathing is then improved. 
A nurse must be kept in constant charge of 
the case after intubation with instructions to 
remove the tube by pulling on the string if 
the dyspnoea become severe ; this with- 
drawal is in most cases immediately followed 
by some relief to the dyspnoea, which may en- 
dure for several hours. Expulsion of the tube 
by cough was observed only in cases in which 
the intubation was done for acute diphtheria, 
and was due to the tube becoming plugged 
with mucous. Scheier does not think that 
the accident was due to the use of too small 
a size. He is inclined to think that the diffi- 
culty m deglutition has been, at least, exag- 
gerated. As a rule, he found there was 
none after the first two or three attempts ; 
when more persistent he believes it to be due 
to the inflammation itself and not to the 
tube. In the treatment of stenosis after 
tracheotomy intubation was very successful, 
whether this stenosis was due to a spur or to 
the formation of granulations. Such granu- 
lations may have formed at the upper or 
lower border of the tracheal wound by the 
time it is proposed to withdraw the trache- 
otomy tube, or they may develop much later 
at the site of the tracheal wound. Scheier 
believes that intubation will also be valuable 
in diphtheria of the wound and skin after 
tracheotomy,; it was also instrumental in sav- 
ing life in a case of severe secondary hemor- 
rhage after tracheotomy. His conclusion is 
that intubation will prove to be a valuable 
auxiliary in the treatment of laryngeal ste- 
nosis due to diphtheria, but that its most im- 
portant field will be in the treatment of 
chronic stenosis of the larynx.-— 



196 



Periscope. 



Vol. lxviii 



The Use of Cocaine. 

1. Amount of cocaine used must be in pro- 
portion to extent of surface it is desired to 
anaesthetize. In no case should the quantity 
exceed •one grain and three-quarters. 

2. Cocaine should never be used in cases of 
heart disease, pulmonary disease, or in per- 
sons of highly nervous temperament. 

3. In injecting cocaine, the intradermic 
method is preferable to hypodermic. By in- 
jecting into, not under mucous membrane or 
skin, the risk of entering a blood vessel is 
avoided. 

4. During injection patient should always 
be in recumbent position; in operations upon 
the nose and throat the head should not be 
raised until anaesthesia is complete. 

5. It is of great importance that cocaine 
should be pure, since its combinations with 
certain other alkalies result in poisonous 
compounds. — Brooklyn Medical Journal. 



Deaths Under Chloroform. 

The stream of deaths from chloroform 
during inhalation still flows on in undimin- 
ished volume, and while much is said and 
written about the methods of restoring col- 
lapsed patients, there is little about how to 
prevent collapse. It has not yet come home 
to doctors generally that the want of oxygen 
is the direct cause of the collapse, but we no- 
tice a practical suggestion of Dr. G. H. Nichol- 
son, of Liverpool, which may lead to some 
good. He advises a combination of oxygen 
with the chloroform-vapour, and says that 
this keeps up the blood-pressure and main- 
tains respiration in a way that gives confi- 
dence to the operator. This is well worth 
trying. — The Chem. and Druggist. 



OBSTETRICS. 

Spontaneous Cure of Rupture of the Uterus. 

Kichter {Deut. Med. Wbch., November 
1892) was called to a case in which during 
labor the pains had ceased, the presenting 
part had retreated, and the patient had sud- 
denly become faint and had vomited. Ab- 
dominal palpation discovered a foot appar- 
ently immediately beneath the abdominal 
wall. The author then seized the other foot, 
turned, and delivered, there being much dif- 
ficulty in getting the head through the con- 
tracted pelvis. The child was born in a con- 
dition of asphyxia; it was " Schultze'd " for 
some time, but without result. The placenta 
had to be removed manually, when a rent 
was found to the front and left of the uterus, 
through which three fingers could be passed 
immediately beneath the abdominal wall. 
No douching was practised. A sandbag 
weighing two pounds was placed on the ab- 
domen, and several doses of ergot given. The 
patient recovered. In all the manipulations 
every antiseptic precaution was taken. The 
case shows that even rupture of the uterus 
may heal spontaneously if septic infection be 
avoided. The slightness of the bleeding 
from the rent was due, in the author's opin- 
ion, to the infant's leg acting as a tampon. — 
Brit. Med. Jour. 



Treatment of Post=Partum Hemorrhage. 

Tarnier (Journ. des Sages Femmes, Decem- 
ber 16th, 1892) strongly insists on the recog- 
nized modern treatment, namely, clearing 
out clots by the introduction of the hand into 
the uterine cavity, followed by hot water in- 
jections. At the same time he advises that 
a small dose of alcohol be given. Should 
these means fail, ergot must be administered ; 
7 or 8 minims of the aqueous solution of er- 
gotinine, hypodermically, act best. If the 
flooding still goes on he advises, before re- 
sorting to the extremity of plugging the ut- 
erus, that an intrauterine injection of the fol- 
lowing solution be given pure:— Tincture of 
iodine 30 parts, iodide of potassium 10 parts, 
distilled water 60 parts. 



GYNECOLOGY. 



Vulvitis with " Gonorrhoea! Rheumatism" 
in a Child aged 2. 

Lop (Gaz. des Hop., No. 42, 1892) relates a 
case of mono-articular arthritis following 
vulvitis in a girl aged 2. It demonstrated 
the close relations between vulvitis in virgins 
and true gonorrhoea. The child was ad- 
mitted into hospital on January 5th, 1892. 
She had suffered from discharge for a fort- 
night; it was free, tenacious, and greenish 
yellow; the vulva was acutely inflamed. On 
the ninth day after the commencement of the 
discharge a painful swelling appeared in the 
right radio-carpal joint. On admission the 
wrist was red, tender, and much swollen. 
There was absence of fever, urethritis, albu- 
minuria, and cardiac or pulmonary compli- 
cation. It appeared that there was no reason 
to suspect venereal taint of any kind. The 
discharge was carefully examined, and gono- 
cocci discovered. Sublimate lotions, and 
painting of the parts with a 5 per cent, solu- 
tion of nitrate of silver soon cured the local 
discharge. After fifteen days of antiseptic 
treatment no more gonococcicould be found. 
At the same time the articular complication 
subsided. Opinion is still divided, but many 
authorities deny that the gonococcus is a 
specific germ, and declare that they have de- 
tected it in the vulvitis of virgins. — Ex. 



ARMY AND NAVY. 



FROM JANUARY 22, 1893, TO JANUARY 28, 

1893. 

Captain Louis W. Crampton, Assistant 
Surgeon, U. S. Army, now on leave of ab- 
sence at Los Angeles, California, will report 
in person to the Commanding General, De- 
partment of Arizona, for such temporarv 
duty at Los Angeles, California, as may be 
required. 

Leave of 'absence for four (4) months, on 
Surgeon's certificate of disability, is granted 
Captain Freeman V. Walker, Assistant Sur- 
geon, U. S. Army, on condition that he spend 
the period of leave as a patient in the Army 
and Navy General Hospital, Hot Springs, 
Arkansas. 



Vol. LXVIII. No. 6. 
Whole No. 1876. 



FEBRUARY II, 1893 



§5.00 per Annum 
10 Cents a Copy 



A WEEKLY JOURNAL. 



THE 



Established 1853, by S. W. Butler, M. D. 



MEDICAL AND SURGICAL 

REPORTER 



Entered as Second-Class Matter at Philadelphia P. O. 



P. O. BOX 843, PHILA, PA* 



ORIGINAL ARTICLES. 

Samuel Mardis Hogan, M. D., Union Springs, Ala. 
The Early Treatment of Congenital Club-Foot . . 197 

John Edward Purdon, A. B., M. D., Tampa, Florida. 
The Physical Import of Variable Achromatopsia; an 
Original Research. 200 

CLINICAL LECTURES. 

John V. Shoemaker, A. M., M. D. 
A Case of Papulo-Squamous Syphiloderm. . . . 205 

COMMUNICATIONS. 

William C. Krause, M. D., Buffalo, N. Y. 
Reflex Disturbances in the Causation of Epilepsy. . 208 

Robert C. Moon, M. D., Philadelphia, Pa. 
A Portable Combined Optometer and Opthalmoscope 
(Opthalmometroscope.) 212 

Andrew F. Currier, M. D., New York City. 
Certain Forms of Septicemia Resulting from Abor- 
tion 



214 



SOCIETY REPORTS. 

The Surgical Society of Louisville ..... 215 

CORRESPONDENCE. 

New York Letter. . . . . . . . . 222 

New York State Medical Society 223 

EDITORIAL 

The Examination of Sputum for Tubercle Bacilli. . 224 

TRANSLATIONS . . . 226- 

ABSTRACTS 230 

THE LIBRARY TABLE .232 

CURRENT LITERATURE ... ... 233 

PERISCOPE 

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THE 

Medical and Surgical 
Reporter. 

No. 1876. PHILADELPHIA, FEBRUARY 11, 1893. Vol. LXVIII— No. 6 

ORIGINAL ARTICLES. 

THE EAELY TEEATMENT OF CONGENITAL CLUB-FOOT. 

SAMUEL MARDIS HOGAN, M. D., Union Springs, Ala. 



In presenting this subject I do so, not 
for the purpose of advancing any new the- 
ory as to the causes of these deformities, 
nor for the purpose of introducing any new 
or original line of treatment, but to en- 
deavor to awaken an interest in these un- 
fortunate cases which will result in their 
obtaining earlier treatment and more speedy 
and permanent cure. 

In order that we may fully appreciate 
the importance of this early treatment we 
should remember that immediately after 
birth not only the ligaments and tendons 
are soft and easily stretched, but even the 
tarsal bones are undeveloped and can be 
moulded into proper shape. At this age, 
too, the growth is rapid and will aid very 
materially in overcoming these deformities 
after we have adopted a course of treat- 
ment suitable to the case. If, however, 
we neglect the treatment of these cases, 
which is so frequently done, there will be 
defective nutrition of the parts and a chang- 
ing of the bony structures that may defy 
all of our resources to rectify. This being 
the case, it is certainly the duty of the at- 
tending physician to institute this treat- 
ment immediately after birth, as every day 
that it is postponed will be valuable time 
lost, for the effects of the pressure on the 
nutrition of the parts will be rapidly mani- 
fested. Structural changes will soon take 
place, which will complicate the treatment 
very materially and may even require an 
operation with the knife. It is true that 
a tenotomy may be required even after the 
best directed efforts, but it will be an ex- 
ception and an exceedingly rare one. In 



making this statement, I know there are 
many eminent surgeons who contend that 
every case should be cut, and notably among 
these is Dr. W. E. Balkwell, of London, 
who, in an article on this subject, read be- 
fore the 9th International Medical Con- 
gress, says: — "The child is brought to you 
at from two to three weeks old, and you 
have to decide when to operate, for operate 
you must ; no extension apparatus is of any 
permanent good." 

Edmund Owens, M. B., F. E. S., who 
also is a surgeon in this same home of the 
specialist, takes an entirely different view, 
and says in his book on the ''Surgical Dis- 
eases of Childhood :" 

"The plaster-of-Paris method enables 
us to treat the club-foot of a tender infant 
with security and success and without the 
expense of a mechanical apparatus re- 
quiring daily attention. 

Thus, children may be dealt with in 
the out-patients' department of a hospital 
or in the out-lying districts of a country 
practice, with as much convenience and 
certainty as if they were inmates of a hos- 
pital." 

In our own country the majority of our 
most successful orthopedic surgeons hold 
that a tenotomy should not be performed 
until it was absolutely necessary. This 
question will be discussed further on, 

The question now arises, how should we 
proceed with the treatment, and in the 
event of failure, when should we resort to 
tenotomy? 

All infants should be carefully exam- 
ined immediately after birth, and if a club- 



198 



Original Articles. 



Vol. lxviii 



foot be found the nurse should be shown 
and fully instructed how to manage the 
case for several weeks. Three or four 
times a day the foot and leg should be 
gently but thoroughly rubbed and kneaded 
and the foot and heel straightened. This 
should be done systematically for three or 
four weeks, when it will generally be found 
that the foot can be placed in a correct po- 
sition with very little force and without 
interfering very materially with the circu- 
lation. Then a plaster-of-Paris dressing 
can be applied and allowed to remain ten 
days or two weeks, when it should be re- 
moved, the foot and leg bathed in warm 
water, well rubbed and kneaded and the 
dressing again applied. This may be re- 
peated for several months, or until the 
contractions have been entirely overcome; 
or it may be advisable, after a few dress- 
ings, to split the plaster-of-Paris dressing 
in front and have the foot taken out every 
day or every four days, and after being 
attended to it can be replaced and easily 
secured with a roller bandage. This dress- 
ing can also be easily arranged so as to use 
the artificial rubber muscles of Dr. Sayre, 
if it should be thought advisable to do so. 
At no time, however, should the plaster- 
of-Paris dressing be applied so as to affect 
injuriously the circulation or produce dis- 
comfort or pain, and we can generals- 
avoid this by first applying a soft, thick 
sock, or a roller bandage of some soft, 
thick material, leaving the toes exposed, 
as suggested by Dr. Owens, and then ap- 
plying the plaster bandage which should 
be done quickly and smoothly, the foot 
being held in the straight position until 
the plaster has firmly set. 

The time may come, however, when 
after carrying out this line of treatment, 
even faithfully and intelligently, the de- 
formity has not been relieved, and we will 
then have to decide whether to operate or 
not. To decide this question, Dr. Sayre 
says: 

(i Distortions or deformities which are 
the result of contractured tissue, can only be 
removed by forcible rupture of the same, 
or by cutting before traction is applied. 

A contracted tissue is one simply short- 
ened but which can be elongated by care- 
ful, continuous and judiciously applied 
traction and manipulation, and therefore 
does not require to be divided. A con- 
tractured tissue is one which has under- 
gone some changes of structure in the fib- 



rillae of the muscles, and which cannot be 
elongated or stretched unless the tissues 
are severed or torn, and therefore sections 
in such cases are absolutely necessary. 
Mr. Little, of London, describes this con- 
dition as one of structural shortening. In 
order to determine which kind of tissue we 
have to deal with he lays down the follow- 
ing rule : 

If in any case of club-foot or other 
deformity we stretch the shortened parts 
to their utmost tension by manual force or 
mechanical aid, and when the parts are 
thus stretched we suddenly add to the ten- 
sion by pressing with the thumb or finger 
on the part thus stretched, or by pinching 
the stretched tissue between the thumb 
and finger, and if, by either of these acts, 
we produce a reflex spasm or sudden shiv- 
ering of the whole body, the muscle, ten- 
don, or tissue thus yielding, the reflex 
spasm is contractured, and cannot be elon- 
gated without the severing of its fibres." 

This teaching of Dr. Sayre has not been 
fully adopted by the profession, but I 
know of no one who denies its correctness 
and, as a rule, his opinion on this subject 
is entitled to the fullest consideration. 

Dr. Edmund Owens says: "If, after 
some weeks of simple plaster-of-Paris 
treatment, the position of the foot, though 
improved, be not entirely corrected, if 
there remain considerable inversion of the 
sole and some drawing up of the imper- 
fectly developed os calcis, a tendon must 
be divided." 

There are yet some other conditions that 
must be eliminated before we proceed to 
cut. If there is any irritation of the cli- 
toris it must be relieved by local applica- 
tion or excision, or if there be phimosis 
circumcision should be performed, as the 
fact has been fully settled that it is almost, 
if not entirely, impossible to cure a case of 
club-foot with either of these conditions 
existing. 

About two years ago I had a patient 
with congenital talipes equino-varus of the 
right foot, in which I commenced this 
treatment immediately after birth. The 
mother and child left as soon after her 
confinement as she was able to travel, and 
I saw no more of the case until he was 
about four months old, when she returned 
with him for further treatment, as im- 
provement seemed to be very slight. 

Upon examination I found both feet 
and legs to be of nearly the same size, and 



February 11, 1893. Original Articles. 



199 



very well developed. If he was the least 
excited it was almost impossible to 
straighten the foot, but whenever I could 
attract his attention, and get him in a 
playful mood, it would take very little 
force to overcome the deformity. This 
satisfied me fully that there was some irri- 
tation somewhere that was keeping up, or 
at least intensifying these contractions 
and, as Dr. Sayre and other surgeons had 
frequently reported such cases, 1 naturally 
examined the penis for the cause and 
found a phimosis and an adherent prepuce. 
I did a circumcision and liberated the ad- 
hesion after which improvement was rapid 
and his recovery seems to be perfect. In 
this case I should have most certainly op- 
erated had I overlooked this source of 
irritation. 

When we have fully decided that an op- 
eration should be done we must then de- 
cide where it should be done, and at this 
point Dr. Sayre lays down this rule : 

" While the patient is anaesthetized put 
the parts under consideration upon the 
stretch to their fullest extent, and while 
thus stretched press with the thumb or 
finger upon the tendon or fascia thus 
stretched, and if this additional pressure 
produces reflex contraction, that tendon or 
fascia must be divided, and the point of 
pressure producing spasms, is the point for 
operation/' 

In performing a tenotomy it is impor- 
tant to have a blunt-pointed tenotome, so 
as to avoid injuring important blood-ves- 
sels and nerves; still we can use a sharp- 
pointed one to puncture the skin and the 
sheath of the tendon if it should be pre- 
ferred. The knife is introduced flatwise 
until it enters the sheath of the tendon, 
when it is passed under the edge, turned 
upwards against it and the tendon severed 
by being pressed upon it; the knife is 
again turned flatwise and removed, pres- 
sure being made with the finger along the 
track to avoid the entrance of air, and the 
wound is hermetically sealed with rubber 
plaster. All of the tendons and fasciae 
are cut necessary to enable you to put the 
foot in proper position. This should be 
done immediately, and the dressing ap- 
plied so as to retain in position until the 
wounds have healed, and the bloody serum 
or lymph that has exuded between the cut 
ends of the tendon becomes organized, which 
will usually take place in about two weeks. 

For this dressing I still prefer the 



plaster-of- Paris, although there are many 
surgeons who prefer others, and each 
of them can be applied with more or 
less success. Those dressings, however, 
that are made with adhesive plaster should 
usually be avoided, as they are so liable to 
irritate the tender skin of the infant. 

The usual point for cutting the tendo 
Achillis is just above its insertion into the 
os calcis, and as the knife is introduced 
into the sheath and just below the tendon, 
there will be no danger of cutting any 
important blood vessels or nerves. The 
tendons of the posterior tibial muscle, 
and the flexor longus digitorum may be 
cut, most conveniently, just above the in- 
ternal malleolus, the patient lying on his 
side. The operation is done on the same 
principles as in dividing the tendo Achillis, 
and the only precaution necessary is to 
avoid cutting the posterior tibial artery 
and nerve, which might be endangered 
by carrying the knife too deeply. Or the 
tendon may be cut below the ankle in its 
passage to the scaphoid bone. The ten- 
don of the tibialis anticus will be found 
in front of the ankle where it may be felt 
as a tense cord, lying somewhat nearer the 
internal malleolus than in its natural 
position, and where it can be very easily 
cut without danger, as the anterior tibial 
artery lies external to it. 

The plantar fascia is to be divided in 
the same manner as we divide tendons, — 
by passing the knife under and cutting 
outwards, and it may be necessary to 
divide it in the posterior portion and 
opposite the metatarsal bone of the great 
toe. Other tendons and fascia may be so 
contracted as to need division. When 
they are put upon the stretch they are 
generally readily detected, and can then 
be divided. 

After division of all tendons, fascia, etc. , 
that may be needed to straighten the foot; 
after healing of all wounds, and after the 
divided tendons have been reunited, it 
will still be necessary to keep the foot in a 
proper position by means of the plaster-of- 
Paris dressing, or some of the many other 
forms of braces, splints or shoes that have 
been devised for such cases. In no in- 
stance .should we relax our efforts to de- 
velop the muscles by daily friction, mas- 
sage, electricity, etc., until the deformity 
has been permanently removed and our 
little patient is able to walk perfectly with 
an ordinary shoe. 



200 



Original Articles. 



Vol. lxviii 



I have purposely avoided going into a 
detailed account of the various appliances 
for such cases because I believe, if the 
treatment is commenced immediately 
after birth and faithfully carried out, you 



can accomplish with the plaster-of-Paris 
dressing, and artificial rubber muscles 
when necessary, everything that could be 
done with the most expensive orthopedic 
appliances, and with much less trouble. 



THE PHYSICAL IMPORT OF VARIABLE ACHROMATOPSIA 
ORIGINAL RESEARCH. 



AN 



JOHN EDWARD PURDON, A. B., M. D., Tampa, Florida. 



The title of my paper is rather a formid- 
able one, but shorn of technical language, it 
is a condensed expression for the implica- 
tion that there exist certain cases of func- 
tional nervous disturbance in which varia- 
bility of the color sensibility is a prominent 
feature, and that such variation is accom- 
panied by changed mental and physical con- 
ditions. 

Color blindness proper, a congenital af- 
fection, does not directly enter into the 
consideration of this class of derangements 
since the color vision in all my cases was 
at times perfect. Indeed the sharpness of 
this function was the inlet by which alone 
I could test the nature of the changes that 
occurred from time to time in the persons 
under observation. 

The name of Mr. William Crookes, E. 
R. S. , the celebrated chemist, is well known 
and his experiments in the line of psychical 
and spiritualistic research are some of the 
most accurate on record. The persons 
named in this paper as furnishing valuable 
physiological data were some of those with 
whom he made his most widely published 
and most startling observations. I have 
in my possession a photograph, prepared 
by Mr. Crookes himself, in which he ap- 
pears with a duplicate of one of the sisters 
of the family I am about to describe, lean- 
ing upon his arm, his own account going 
to show that her natural body was at the 
same instant lying in a state of trance be- 
hind the curtain before which he was 
standing with her double leaning on his 
arm. I do not here offer any explanation 
of the modus operandi by which this ethe- 
real body was produced, that being beside 
our present purpose; but I do offer what 
I regard as of much more importance to 
us as physiologists, namely, accurate notes 
taken regarding the state of that most 

;;; Surgeon Major, Retired (British Army.) 



sen- 



complex but most directly presented 
sorial function, vision, under circum- 
stance directly parallel to those holding 
when Mr. Crookes obtained his physical 
data from members of the same family. 
No one who is inclined to place even a 
very small amount of trust in me as an ob- 
server will feel justified in ignoring the 
value of these case notes. If these are of 
no more value than to show that appar- 
ently simple sensorial entities are in real- 
ity very complex — being constructed out 
of simpler elements of feeling and so liable 
to disturbance on account of the different 
possibilities of arrangement of such ele- 
ments in time, number and order — the re- 
search is of certain value from an educa- 
tional point of view. As a practical mat- 
ter the inquiry is also useful, for it tends 
to show that under conditions of nervous 
disturbance and specific excitement the 
natural signs and landmarks of objective 
nature are interfered with. The research 
shows that the colors so familiar and so 
fixed may vanish for the time being with- 
out interference with the general con- 
sciousness or decadence of the intellectual 
powers, to be restored after a time to their 
full recognition as permanent elements of 
healthy sensation. 

But it is as a step into the mysterious 
region of the unknown, between which and 
us the sensorial barriers become broken 
down on occasions, that I attach value to 
such an inquiry. In a word, the ladies 
whose sensorial disturbances I record in 
this paper were what are called mediums 
or psychic sensitives, who have been re- 
peatedly certified to as producing the most 
genuine and startling manipulations of an 
unknown power by Alfred Russell Wallace, 
the great evolutionist, William Crookes, 
the celebrated chemist and physicist, and 
many others distinguished in art, litera- 



February 11, 1893. Original Articles. 



201 



ture and science. Anything of a physio- 
logical nature, out of the common, during 
and after such manipulations must be 
worth recording and I hope will be my 
excuse for venturing to present a subject 
so far out of the beaten track. 

During the last three years I have been 
bringing before the profession, through 
two of the leading medical societies of the 
South, certain physiological and psychical 
matters which I believe to be calculated to 
throw light upon that mysterious depart- 
ment of psychology which goes under the 
name of "Psychical Eesearch." On the 
present occasion I have selected the sub- 
ject of variable color vision as being one 
which was urged upon my attention from 
the fact that I found its most marked in- 
dication in the members of a family well 
known to students of the occult, and who, 
some fifteen to twenty years ago, were re- 
garded as some of the best mediums in 
England for the manifestations of the 
mysterious psychic force which has been 
the great puzzle and paradox of this gen- 
eration. 

In the middle of the year 1871 I com- 
menced the practical study of psychic 
science and some months after, I had my 
attention called to peculiar periodical vari- 
ations of visual functions in the case of a 
young lady sensitive with whom I was ex- 
perimenting. I perceived that she suf- 
fered from what I afterwards found was 
described by Charcot as the hysterical eye, 
or, at any rate, that her case was related 
to the latter. For the greater part of 
each month she suffered from weakness of 
one eye with loss of accommodation and 
imperfection of color vision which, how- 
ever, were both corrected by a 7 or 8 -inch 
minus glass. She also perceived black bands 
or rings drawn on paper to be thickened and 
doubled in a certain uniform way when 
observed through the uncorrected eye, 
although the sight of the other eye was 
very good. As this young lady was at 
that time becoming famous as a medium I 
eagerly embraced every opportunity that 
offered to study such cases as hers in the 
hope of finding some clue to the nature of 
the changes that take place in the cere- 
bral machinery whenever there were pres- 
ent manifestations indicative of the ac- 
tivity of psychic force. I noticed that at 
a certain time each month both the power to 
manifest the special psychic activity and 
the abnormal vision disappeared together, 



leaving the inference to be drawn that ab- 
normal color and ray vision and the psy- 
chic potentiality co-existed in her case 
and most probably were related in conse- 
quence of a strained condition of certain 
parts of t the brain to be determined by 
other observations. 

Further experience tended to confirm 
this view, for I found in the case of this 
young lady, during actual manifestations 
of great psychic power, a total disorganiza- 
tion of distinct color perception and dis- 
crimination while the evidence of brain 
strain and congestion was furnished by 
profuse nose bleeding coming on during 
the actual exercise of the psychic power. 
My attention having been turned in this 
direction I found several instances of 
analogous color vision disturbance in 
patients of mine who were haunted by 
subjective spectral figures not dependent 
upon drink, opium or similar exciting 
causes. I think I may safely say that in 
all these cases the cardiac innervation was 
imperfect — a sign of the general condition 
of the nervous system. 

Some years after I first noticed the 
above relations I had good opportunities 
of studying the vision pecularities of two 
sisters of the first mentioned medium, 
both bright and intelligent young women, 
who did their best to assist me in my re- 
search. The elder of these sisters, Miss 
K. C, was affected in the left eye, gener- 
ally corrected by a minus glass as in the 
case of her eldest sister. The younger, 
Miss E. 0., was affected in the right eye, 
generally corrected by a plus glass. This 
interesting contrast was verified again and 
again. Their ages were 24 and 18 years. 

In my examination of these girls I used 
Holmgren's wools and colored glasses 
of many shades, and the colors were ob- 
tained by passing polarized light through 
doubly refracting crystals, the latter being 
very convenient for the study of comple- 
mentary colors and the variations occur- 
ring in the perception of the same. 

In submitting the following notes I 
wish them to be regarded as an account 
of qualitative experiments made under 
conditions quite unfavorable to qualitative 
and more, properly speaking, scientific 
observations. I can at any rate vouch for 
them as representing the facts and as 
fully supporting my trust in the value of 
similar experiences with other persons of 
the mediumistic or sensative temperament. 



202 



Original Articles. 



Vol. lxviii 



I can positively say that I have never per- 
ceived a gross contradiction correspond- 
ing with an attempt to deceive. Order 
in disorder, for the time being, is what I 
have observed. Any new departure, cor- 
responding to some fresh peculiarity of 
the sensitive organization, had only to be 
followed up to be identified as a member 
of a class. 

April 29th, 1883, Miss K. C, a won- 
derful medium for all kinds of psychical 
manifestations, was examined with the 
double image prism previous to seance. 
She could see with the left eye but one 
image of a pencil mark ring on white 
paper — that one which was most refracted. 
She placed the point of a pencil a good 
way outside the circumference of the cir- 
cle when asked to put it exactly in the 
centre. As the paper was moved the 
ring was unstable in its position. The 
prism showed two rings in the ordinary 
manner to the right eye. After the 
seance she could not see at all with the 
left eye. The right eye remained un- 
affected. 

Miss E. C, before the seance, saw the 
two images through the double image 
prism, but much separated from each 
other. She also remarked, when she 
looked at the ground glass globe of the 
gas lamp, that one of the images, that 
which was most refracted, showed broad 
color bands taking up nearly the whole 
of the outline, in place of the normal 
mere edging of color. 

May 2nd, Miss K. C, could see only 
one image through the double image prism 
held to the left eye. When the eye was 
supplied with a seven-inch minus glass 
she saw both images quite well. An ex- 
periment was then made with plates of 
selenite between two Nicol's prisms. The 
color of the purple and greenish yellow 
selenite were called blue and j^ellow, but 
when the true blue and yellow selenite 
was placed between the two NicoPs prisms 
the colors were not recognized at all. 
Thus it appears that red and green, which 
were components of the purple and green- 
ish yellow, were unperceived in the first 
pair of colors, while the blue and yellow, 
the inferred perception after such abstrac- 
tion, were not perceived when directly 
presented in the second pair of selenite 
colors. After the seance, which was a 
very good one, the medium could not see 
with the left eye : the correcting concave 



glass, which was useful before the seance, 
having, after it was over, no effect in 
restoring her sight. The circulation, 
judging from the radial pulse, was weaker 
on the left side than on the right after 
seance, and neither ring could be seen 
through the double image prism. 

Miss E. 0. was examined before the 
seance with the double image prism and 
also with the selenite plates. She saw the 
two images correctly and also the colors, 
but afterwards, though she could see the 
two images through the prism she had 
lost all sensibility for color on the affected 
side. Both the young ladies were ex- 
amined with the colored wools after the 
seance and both had lost all power of dis- 
tinction. 

A careful observer called my attention 
to a circumstance she had noticed and 
which had a bearing upon the variation 
of color perception in the case of Miss K. 
0. On the fourth of May, after walking 
through town and feeling tired she was 
affected with transient right hemianopsia ; 
that is, she saw with the left half of each 
retina, the other half being but little re- 
sponsive to the stimulus of light, or 
rather the visualizing centers in connect- 
ion therewith. But the dark half- field 
proved on trial to be more marked for the 
right eye than for the left. When look- 
ing at a face she saw only half of it, but 
she could see distinctly the whole of a 
bright gas flame. With the left eye she 
could see a shaded half face, the other 
half being distinct, while with the right 
eye she could see only the half face, the 
other half being perfectly blank. When 
examined, the purple and yellowish green 
selenite being placed between two Nicol's 
prisms, the left eye saw the colors cor- 
rectly, but to the right eye the red-violet 
or purple was reduced to blue, and the 
greenish-yellow to yellow; that is to say, 
the red was cut out in one case and the 
green in the other. Shortly after the 
examination, while moving about, she got 
a headache across the eyes, when on trial 
the hemianopsia had disappeared and the 
colors were the same exactly to the two 
eyes. 

This lady at times, when similarly ex- 
posed to the sun and to fatigue, had be- 
come temporarily aphasic, evidently on 
account of irregular circulation in the 
cerebral cortex. Physiologically speaking, 
her case was in many respects an exact 



February 11, 1893. Original Articles 



203 



parallel to those of the psychic mediums 
here described, and therefore, calculated 
to throw some light upon them. 

May 6 th Miss K. 0. was examined in 
good light before the seance. She had 
remarked while out walking with me that 
the red and yellow tulips appeared to her 
as "gray." Examined with the colored 
wools — red, dark red, blue, dark blue, 
liffht blue, yellow and blue green were all 
called "gray." A 7-inch minus glass cor- 
rected the achromatopsia completely. 
When using the double image prism she 
saw but one ring with the left eye, but 
with the minus glass added she saw both 
rings. When a beam of polarized light from 
a Nicol's prism was passed through plates of 
selenite and the double image prism added 
to complete the combination, she saw the 
double beam in complementary colors with 
the right eye, its normal appearance, but 
to the left eye it showed as a single color- 
less beam. This was true for the blue- 
yellow selenite, and also for the red-green, 
or more properly, blue-red and yellow- 
green ; a single colorless image was in all 
cases perceived. When, however, the left 
eye was armed with the 7- inch minus or 
concave glass, the vision of the left eye 
was exactly the same as the right. After 
the seance (and I may remark that all the 
seances here referred to were satisfactory 
in the way of manifestations of extra- 
ordinary activity,) she could not see at all 
with the left eye, neither color nor ray 
vision remained. The glass before so 
marked in its effect did not restore the 
color of the wools, which were all de- 
scribed as "grays." 

Miss E. C. was examined the same day. 
She called the green, blue and yellow 
wools 4 'gray. " Dark blue was called very 
dark gray. The cherry red and dark red 
she called "dark red" and "very dark 
red." With the double image prism both 
eyes behaved alike, vision being normal. 
A check experiment was then tried. On 
overlapping one of the images of a piece 
of green glass looked at through the 
double image prism, by one of those of a 
piece of red glass placed near it, both 
being held up against the light, she did 
not perceive the change that under ordi- 
nary circumstances is due to the superpo- 
sition of lights of different colors; she 
simply experienced the sensation of red- 
ness, the green being entirely absent from 
her perception. The images of blue and 



yellow glass overlapped appeared as "gray" 
without any change being noticed. The 
eye was then reinforced by a strong con- 
vex glass and she saw all the colored ob- 
jects when brought to a distance of four 
inches from the eye — the green required 
to be brought nearest. Outside of that 
distance the red alone was seen as a dif- 
fused light red. When tried with the 
selenite plates she saw the red-violet and 
yellowish-green as violet and yellow using 
her sound left eye, but with the right eye, 
that which was the peculiar one, she saw 
only the red or red-purple shade, the 
yellowish-green complementary being en- 
tirely absent. 

This young lady was examined after the 
seance, during which she was for a short 
time "entranced." It was found that she 
had lost all color sensation on the left side. 
The double image prism showed double 
images without color; the wools were all 
"gray" to the left eye. She remarked 
that the double images of a pencil mark 
ring as seen by the left eye appeared much 
larger than those seen by the right eye. 
They had to be brought much nearer to 
the eye before their circumferences touched 
than in the case of those seen by the right 
eye; say, about five inches in the former 
case, and ten in the latter. Before the 
seance this distance was the same for both 
eyes, as I had noticed after careful obser- 
vation. 

May 27th. Before the seance Miss K. 
0., in day light, saw through the double 
image prism two images when using the 
weak left eye, though she could not per- 
ceive the colors of any of the wools offered 
for inspection. The sight of the right eye 
was quite normal. After the seance she 
saw but one image of a ring drawn on pa- 
per through the prism when the left eye 
was used. The concave glass corrected the 
defect and enabled her to see both. Dur- 
ing the seance, which was held in the 
dark, and where many lights were seen 
flitting about, she remarked that she could 
not see the lights doubled by the prism. 
She over- and over again said she saw the 
lights very small and single, and this she 
said was the case with the two eyes. 
While examining her after the seance and 
while her weak left eye was corrected with 
the concave glass, to enable her to see the 
double image of the ring, pressure was ac- 
cidentally made on the right eye-ball, that 
eye being closed at the time; she immed- 



204 



Original Articles. 



Vol. lxviii 



iately remarked that she saw four images ! 
This extraordinary observation was repeat- 
ed again and again with the same result. 
These images did not fade out as the prism 
was turned round. Before, when she saw 
the second image through the concave 
glass, one image faded out as the prism 
was turned. On the same occasion Miss 
E. C. could see the double image through 
the prism before and after the seance. 
She saw the colored wools somewhat better 
than usual ; she could see red pretty well, 
both dark and light, but she called the 
blues "greens," and the yellows "gray," 
During the seance, she declared that she 
saw the lights which appeared in the dark, 
room double, but this proved on examina- 
tion to be in all probability due to want of 
proper adjustment of the axes of the eyes, 
so as to let the rays fall on corresponding 
points of the retinse ; for when each eye 
was closed in turn the lights appeared 
to be single in the open eye. I merely 
mention this to show that rational precau- 
tion against error was always observed. 

It appeared from observation that every 
•member of the family, including the 
mother three daughter sand one son were 
more or less the subjects of abnormal color 
sensibility. It was ascertained that Mrs. 
C, the mother, possessed the following 
remarkable peculiarity: On being given 
light pink wool to match, the left eye being 
closed at the time, she picked out a darker 
pink from a group of colored wools. She 
was then given the same pink to match, 
the right eye being closed, and she picked 
out a very light brown. But strange to 
say she matched colors well when using 
both eyes. She generally makes choice of 
lighter shades with the left than with the 
right eye singly. There was also in the 
case of her son, a youth of 18 years, a dif- 
ference of color appreciation on the two 
sides without pronounced achromatopsia, 
as in the case of his three sisters. 

The following notes are very interesting 
as throwing light upon the puzzling ques- 
tion of deranged color vision : 

Miss K. C. was examined with colored 
glasses on January 16, 1882. On that 
occasion she exhibited the remarkable pe- 
culiarity of reverse color vision for red and 
green. When green glass was held to her 
left eye, the right being closed, she at once 
said, ' ' red, a nice bright red. " This was 
said to be the same sensation as when red 
glass was held to the left eye, the right 



being closed, it was called "green." It 
was said to cause nearly the same feeling 
as when green glass was held before the 
right eye. The same was found to be the 
case after a seance on the 18th of January, 
the colors, however, being darkened, while 
yellow light was called "gray," and blue 
and yellow light " black." All the colors 
were restored when a concave glass was 
held outside the colored plate at a distance 
of four inches. When held closer to the 
eye it had no effect. These experiments 
were several times repeated with the same 
result. 

On January 29th, 1892, an interesting 
observation was made in the case of the 
eldest sister with whom I had experi- 
mented ten years before, and with whom 
I had first studied the psychical import of 
variable color vision. When a plate of 
green glass was held before her weak eye 
she said the light was "gray," but imme- 
diately on its removal she saw "violet." 
When red glass was held to her eye she 
said it was "gray;" then, when it was 
taken away, she said she experienced the 
sensation "green." This may be relied 
on as certain. With her good eye this re- 
markable peculiarity was less pronounced. 
It will be seen that it gives the key to the 
reverse visions of her sister, described 
above. The elder sister showed what I 
may call semi-reversal. 

It appears from these results that both 
red and green sensations may be excited 
by the same physical cause ; but the spe- 
cial sensation is determined by the state of 
the organism at the time. The theory of 
color blindness advanced by Mr. W. Stan- 
ley Monck of Trinity College, Dublin, re- 
ceives support from the above observations 
on reverse vision. His idea was that in 
true color blindness owing to a functional 
peculiarity of the organism the pair of 
complementary colors were excited to- 
gether with a neutralizing effect, by the 
presence of the stimulus corresponding to 
either of them acting on the retinal expan- 
sion. 

The conclusions to be drawn from these 
experiments appear to me as follows: 

1st. Nervous states with a tendency to 
hysteria may be accompanied by a derange- 
ment of accommodation in one or both 
eyes, which is indicative of a more general 
defect of " attention " on the part of au- 
tomatic centers of the brain, whereby the 
elements of sensation are generally com- 



February 11, 1893. 



Clinical Lectures. 



205 



bined into higher psychical complexes. 
Observation with the ophthalmoscope and 
otherwise led me to the belief that func- 
tional inactivity depends rather upon a 
deficient supply of blood than upon direct 
inhibition. I found that forced attention 
restored the visual function in one of the 
sisters when I used a distorting instru- 
ment, " Stokes lens," to excite her curi- 
osity when looking at small type. 

2nd. The existence of this state is a 
predisposing cause in the manifesting of 
psychic phenomena, such as are usually 
shown by respectable mediums under test 
conditions, at least in the instances of the 
young ladies here referred to; while the 
nose bleeding and the aggravation of visual 
defects in them gave direct evidence of 
congestion or stasis of blood in the brain, 
and probably also of anaemia in varying 
and unknown degrees ; the latter supposi- 
tion being supported by the trains of ob- 
jective nervous symptoms so commonly 
seen in the case of ' 4 mediums " during 
" manifestation." 

3d. The actual occurrence of extraor- 
dinary psychical events being provisionally 



granted for the sake of an application of 
physiological theory, it appears very prob- 
able that the relationship of the cerebral 
cortex to the muscular system is pro- 
foundly modified, and to such an extent 
that psychical states find other modes of 
expression than those depending upon the 
mechanical influence of a visible and tang- 
ible intervening substance, the nervous sys- 
tem being thereby placed in a more direct 
relationship with the space content. 

The correlation of the visual and mus- 
cular systems being found by observation 
and experiment to have been interfered 
with, it is allowable to speculate upon pos- 
sible manifestations of physical activity in 
which heat does not play so prominent a 
part on the physical side of the sequence, 
other modes of vibratory action taking its 
place, with a corresponding change in the 
psychical chain. There is a complete an- 
alogy afforded in the region of mechanical 
philosophy when physicists attempt the 
direct transformation of latent energy 
without the intervention of the steam 
(heat) engine, muscle being a heat engine 
and the most economical that we know of. 



CLINICAL LECTURES. 



A CASE OF PAPULOSQUAMOUS SYPHILODERM. 

JOHN V. SHOEMAKER, A. M., M. D. ,* 



B. H., 28 years of age, male, single, 
and a laborer, gives the following history: 
About 6 months ago a number of blisters 
appeared on the toes of both feet. Con- 
tiguous blisters coalesced, formed large 
bullae and his feet were for some time so 
sore that he could not wear shoes. Three 
weeks after the appearance of the vesicles 
papules also developed upon the feet. The 
lesions were of considerable dimensions, 
some being as large as 3 and 5 cent pieces. 
In a short time similar papules were ob- 
served upon the shoulders, front of chest 
and upon both upper and lower limbs. 
The vesicles upon the feet ruptured and 
discharged serum, but he never saw any 
pus. 

Upon examination there were observed 
upon the forehead and scattered over the 

^Professor of Skin and Venereal Diseases in The 
Medico-Chirurgical College of Philadelphia. 



hairy scalp pa